Cardiovascular risk reduction in older people with type 2 diabetes mellitus-a comprehensive narrative review

Metabolic targets are controversial in older people with type 2 diabetes due to functional heterogeneity and morbidity burden. Tight blood pressure and metabolic control appears beneficial in fit individuals who are newly diagnosed with type 2 diabetes and have fewer comorbidities. The benefits of low blood pressure and tight metabolic control is attenuated with the development of comorbidities, especially frailty. Guidelines consider frail older people as one category and recommend relaxed targets. However, sarcopenic obese frail individuals may benefit from tight targets and intensification of therapy due to their unfavourable metabolic profile, accelerated diabetes trajectory and high cardiovascular risk. In addition, the early use of sodium glucose transporter-2 inhibitors and glucagon like peptide-1 receptor agonists may be beneficial in this frailty phenotype due to their cardio-renal protection, which is independent of glycaemic control, provided they are able to engage in resistance exercise training to avoid loss of muscle mass. In the anorexic malnourished frail individual, early use of insulin, due to its weight gain and anabolic properties, is appropriate. In this phenotype, targets should be relaxed with deintensification of therapy due to significant weight loss, decelerated diabetes trajectory and increased risk of medication side effects.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Delirium and Delirium Severity Predict the Trajectory of the Hierarchical Assessment of Balance and Mobility in Hospitalized Older People: Findings From the DECIDE Study

BACKGROUND

Delirium is common, distressing, and associated with poor outcomes. Despite this, delirium remains poorly recognized, resulting in worse outcomes. There is an urgent need for methods to objectively assess for delirium. Physical function has been proposed as a potential surrogate marker, but few studies have monitored physical function in the context of delirium. We examined if trajectories of physical function are affected by the presence and severity of delirium in a representative sample of hospitalized participants older than 65 years.

METHOD

During hospital admissions in 2016, we assessed participants from the Delirium and Cognitive Impact in Dementia study daily for delirium and physical function, using the Hierarchical Assessment of Balance and Mobility (HABAM). We used linear mixed models to assess the effect of delirium and delirium severity during admission on HABAM trajectory.

RESULTS

Of 178 participants, 58 experienced delirium during admission. Median HABAM scores in those with delirium were significantly higher (indicating worse mobility) than those without delirium. Modeling HABAM trajectories, HABAM scores at first assessment were worse in those with delirium than those without, by 0.76 (95% CI: 0.49-1.04) points. Participants with severe delirium experienced a much greater perturbance in their physical function, with an even lower value at first assessment and slower subsequent improvement.

CONCLUSIONS

Physical function was worse in those with delirium compared to without. This supports the assertion that motor disturbances are a core feature of delirium and monitoring physical function, using a tool such as the HABAM, may have clinical utility as a surrogate marker for delirium and its resolution.

81 An Audit of Venous Thromboembolism (VTE) Risk Assessment & Prophylaxis Implementation

Introduction

VTE is considered one of the most common preventable causes of death and significant co-morbidity in inpatients and is responsible for approximately 60,000 deaths occur per annum in the UK. The NHS Standard Contract requires all inpatients to undergo a VTE risk assessment, with a 95% patient assessment threshold. In January 2020 we identified that 72% of patients within our trust had a risk assessment completed, and 15% of these were accurate. We subsequently implemented mandatory VTE prescribing training for all junior doctors joining the trust.

Aim

Review the impact of mandatory training module on VTE risk assessment and prescribing, in compliance with NICE Guidelines.

Method

All inpatient medical notes, VTE risk assessments, and VTE prescriptions were reviewed to assess accurate risk assessment completion and subsequent appropriate prophylaxis prescribing. The standards were as set out in the NICE guidelines [NG89]. Paediatric, Obstetric and ITU patients were excluded.

Results

Our VTE risk assessment completion rates increased from 72.1% to 94.2%, and the accuracy of these assessments from 15.4% to 34.5%. Our prescription rate increased from 84.6% to 90.6%, and prescribing accuracy from 41.2% to 79.5%.

Conclusions

By implementing mandatory VTE prophylaxis training for all junior doctors joining a new NHS trust, we can see increased compliance with appropriate risk assessment and prophylaxis prescribing. This will reduce the risk of unnecessary death from VTE in hospital inpatients.

Cerebrospinal fluid neurofilament light predicts the rate of executive function decline in younger-onset dementia

INTRODUCTION

Determining disease severity and predicting prognosis in younger onset-dementia (YOD) remains challenging. Whether CSF biomarkers neurofilament light (NfL), tau and amyloidβ 42 (Aβ42) can help provide such information has been underexplored.

METHODS

Patients with YOD and CSF analysis were identified. We compared baseline NfL, tau and Aβ42 concentrations with contemporaneous Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG) scores to assess their association with severity of cognitive impairment. Cognitive decline, as measured by longitudinal NUCOG assessment, was correlated against baseline biomarker levels to assess their utility in predicting the rate of cognitive decline.

RESULTS

78 patients with YOD (mean age = 56 years, SD = 8) and CSF analysis were identified. Dementia types included Alzheimer's disease, behavioural variant frontotemporal dementia, dementia not-otherwise-specified and other. Tau was associated with contemporaneous memory dysfunction (r = -0.556, 95% CI:[-0.702,-0.393], p < .001). 21 patients had longitudinal cognitive assessment up to 82 months from CSF sampling. NfL was associated with the rate of executive function decline (r = 0.755, 95% CI:[0.259,0.937], p < .001). Aβ42 was associated with the rate of memory decline (r = -0.582, 95% CI:[-0.855,-0.274], p = .007) and rate of total NUCOG decline (r = -0.515, 95% CI: [-0.809, -0.227], p = .017).

CONCLUSION

CSF tau is related to contemporaneous memory impairment in YOD. NfL and Aβ42 levels are associated with the rate of executive function and memory decline, respectively, and may have a role in prognostication in YOD.

Evaluation of Bedside Tests of Attention and Arousal Assessing Delirium in Parkinson's Disease, Dementia, and Older Adults

BACKGROUND

Delirium is a serious acute neuropsychiatric condition associated with altered attention and arousal.

OBJECTIVE

To evaluate simple bedside tests for attention and arousal to detect delirium in those with and without Parkinson's disease (PD) and dementia.

METHODS

Participants from two prospective delirium studies were pooled comprising 30 with PD without cognitive impairment, 24 with Lewy body cognitive impairment (PD dementia or dementia with Lewy bodies), 16 with another dementia and 179 PD and dementia-free older adults. Participants completed standardised delirium assessments including tests of attention: digit span, Memorial Delirium Assessment Scale (MDAS) attention and months of the year backwards; and arousal: Glasgow Coma Scale (GSC), Observational Scale of Level of Arousal (OSLA), Modified Richmond Agitation Scale and MDAS consciousness. Delirium was diagnosed using the DSM-5 criteria.

RESULTS

On their first admission, 21.7%participants had prevalent delirium. Arousal measures accurately detected delirium in all participants (p < 0.01 for all), but only selected attention measures detected delirium in PD and dementia. In PD and dementia-free older adults, impaired digit span and OSLA were the optimal tests to detect delirium (area under the curve [AUC] = 0.838, p < 0.001) while in PD and dementia the optimal tests were MDAS attention and GCS (AUC=0.90 and 0.84, respectively, p < 0.001 for both).

CONCLUSION

Simple bedside tests of attention and arousal at a single visit could accurately detect delirium in PD, dementia and PD and dementia-free older adults; however, the optimal tests differed between groups. Combined attention and arousal scores increased accuracy, which could have clinical utility to aid the identification of delirium neurodegenerative disorders.

What matters to people with multiple long-term conditions and their carers?

BACKGROUND

The number of people living with multiple long-term conditions is increasing worldwide. This presents challenges for health and care systems, which must adapt to meet the needs of this population. This study drew on existing data to understand what matters to people living with multiple long-term conditions and identify priorities for future research.

METHODS

Two studies were conducted. (1) A secondary thematic analysis of interview, survey and workshop data collected from the 2017 James Lind Alliance Priority Setting Partnership for Older People with Multiple Conditions, and patient and public involvement workshops; (2) a review of ongoing research and published research priorities, relating to older people (80+) living with multiple long-term conditions.

FINDINGS

Older people with multiple long-term conditions identified a number of key concerns: access to care, support for both the patient and their carer, physical and mental health and well-being and identifying opportunities for early prevention. The review identified no published research priorities or ongoing research focusing specifically on populations aged over 80 years with multiple long-term conditions.

CONCLUSION

Older people living with multiple long-term conditions experience care that is inadequate for their needs. A holistic approach to care that extends beyond treating single conditions will ensure wide-ranging needs are met. As multimorbidity rises worldwide, this is a critical message for practitioners across health and care settings. We also recommend key areas that should be given greater focus in future research and policy to inform effective and meaningful forms of support for people living with multiple long-term conditions.

What matters to people with multiple long-term conditions and their carers?

BACKGROUND

The number of people living with multiple long-term conditions is increasing worldwide. This presents challenges for health and care systems, which must adapt to meet the needs of this population. This study drew on existing data to understand what matters to people living with multiple long-term conditions and identify priorities for future research.

METHODS

Two studies were conducted. (1) A secondary thematic analysis of interview, survey and workshop data collected from the 2017 James Lind Alliance Priority Setting Partnership for Older People with Multiple Conditions, and patient and public involvement workshops; (2) a review of ongoing research and published research priorities, relating to older people (80+) living with multiple long-term conditions.

FINDINGS

Older people with multiple long-term conditions identified a number of key concerns: access to care, support for both the patient and their carer, physical and mental health and well-being and identifying opportunities for early prevention. The review identified no published research priorities or ongoing research focusing specifically on populations aged over 80 years with multiple long-term conditions.

CONCLUSION

Older people living with multiple long-term conditions experience care that is inadequate for their needs. A holistic approach to care that extends beyond treating single conditions will ensure wide-ranging needs are met. As multimorbidity rises worldwide, this is a critical message for practitioners across health and care settings. We also recommend key areas that should be given greater focus in future research and policy to inform effective and meaningful forms of support for people living with multiple long-term conditions.

Are medical procedures that induce coughing or involve respiratory suctioning associated with increased generation of aerosols and risk of SARS-CoV-2 infection? A rapid systematic review

BACKGROUND

The risk of transmission of SARS-CoV-2 from aerosols generated by medical procedures is a cause for concern.

AIM

To evaluate the evidence for aerosol production and transmission of respiratory infection associated with procedures that involve airway suctioning or induce coughing/sneezing.

METHODS

The review was informed by PRISMA guidelines. Searches were conducted in PubMed for studies published between January 1st, 2003 and October 6th, 2020. Included studies examined whether nasogastric tube insertion, lung function tests, nasendoscopy, dysphagia assessment, or suctioning for airway clearance result in aerosol generation or transmission of SARS-CoV-2, SARS-CoV, MERS, or influenza. Risk of bias assessment focused on robustness of measurement, control for confounding, and applicability to clinical practice.

FINDINGS

Eighteen primary studies and two systematic reviews were included. Three epidemiological studies found no association between nasogastric tube insertion and acquisition of respiratory infections. One simulation study found low/very low production of aerosols associated with pulmonary lung function tests. Seven simulation studies of endoscopic sinus surgery suggested significant increases in aerosols but findings were inconsistent; two clinical studies found airborne particles associated with the use of microdebriders/drills. Some simulation studies did not use robust measures to detect particles and are difficult to equate to clinical conditions.

CONCLUSION

There was an absence of evidence to suggest that the procedures included in the review were associated with an increased risk of transmission of respiratory infection. In order to better target precautions to mitigate risk, more research is required to determine the characteristics of medical procedures and patients that increase the risk of transmission of SARS-CoV-2.

Measuring frailty in younger populations: a rapid review of evidence

OBJECTIVES

Frailty is typically assessed in older populations. Identifying frailty in adults aged under 60 years may also have value, if it supports the delivery of timely care. We sought to identify how frailty is measured in younger populations, including evidence of the impact on patient outcomes and care.

DESIGN

A rapid review of primary studies was conducted.

DATA SOURCES

Four databases, three sources of grey literature and reference lists of systematic reviews were searched in March 2020.

ELIGIBILITY CRITERIA

Eligible studies measured frailty in populations aged under 60 years using experimental or observational designs, published after 2000 in English.

DATA EXTRACTION AND SYNTHESIS

Records were screened against review criteria. Study data were extracted with 20% of records checked for accuracy by a second researcher. Data were synthesised using a narrative approach.

RESULTS

We identified 268 studies that measured frailty in samples that included people aged under 60 years. Of these, 85 studies reported evidence about measure validity. No measures were identified that were designed and validated to identify frailty exclusively in younger groups. However, in populations that included people aged over and under 60 years, cumulative deficit frailty indices, phenotype measures, the FRAIL Scale, the Liver Frailty Index and the Short Physical Performance Battery all demonstrated predictive validity for mortality and/or hospital admission. Evidence of criterion validity was rare. The extent to which measures possess validity across the younger adult age (18-59 years) spectrum was unclear. There was no evidence about the impact of measuring frailty in younger populations on patient outcomes and care.

CONCLUSIONS

Limited evidence suggests that frailty measures have predictive validity in younger populations. Further research is needed to clarify the validity of measures across the adult age spectrum, and explore the utility of measuring frailty in younger groups.

An absolute risk-guided approach to cardiovascular risk management within a chest pain clinic: the ARCPAC randomized trial

Background

The majority of patients attending chest pain clinics are found not to have a cardiac cause of their symptoms, but have a high burden of cardiovascular risk factors that may be opportunistically addressed. Absolute risk calculators are recommended to guide risk factor management, although it is uncertain to what extent these calculations may assist with patient engagement in risk factor modification.

Purpose

We sought to determine the usefulness of a proactive, absolute risk-based approach, to guide opportunistic cardiovascular risk factor management within a chest pain clinic.

Methods

This was a prospective, open-label, blinded-endpoint study in 192 enhanced risk (estimated 5-year risk ≥8%, based on Australian Absolute Risk Calculator) patients presenting to a tertiary hospital chest pain clinic. Patients were randomized to best practice usual care, or intervention with development of a proactive cardiovascular risk management strategy framed around a discussion of the individual's absolute risk. Patients found to have a cardiac cause of symptoms were excluded as they constitute a secondary prevention population. Primary outcome was 5-year absolute cardiovascular risk score at minimum 12 months follow up. Secondary outcomes were individual modifiable risk factors (lipid profile, blood pressure, smoking status).

Results

192 people entered the study; 100 in the intervention arm and 92 in usual care. There was no statistical difference between the two groups' baseline sociodemographic and clinical variables. The intervention group showed greater reduction in 5-year absolute risk scores (difference −2.77; p&lt;0.001), and more favourable individual risk factors, although only smoking status and LDL cholesterol reached statistical significance (table).

Conclusion

An absolute risk-guided proactive risk factor management strategy employed opportunistically in a chest pain clinic significantly improves 5-year cardiovascular risk scores.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Tasmanian Community Fund

South Africans' understanding of and response to the COVID-19 outbreak: An online survey

BACKGROUND

The COVID-19 outbreak is in an accelerating phase, and South Africa (SA) has had the highest number of documented cases during the early phase of the pandemic in sub-Saharan Africa.

OBJECTIVES

To assess South Africans' understanding of and response to COVID-19 during the first week of the country's lockdown period.

METHODS

An online survey was conducted in SA from 27 March to 2 April 2020. The survey was distributed widely among several websites and social media networks, including on a data-free platform. Descriptive statistics of knowledge, risk perception, access to and trust in information sources, and public and media opinions were calculated. Estimates were benchmarked to the 2019 national adult population estimates.

RESULTS

Of the 55 823 participants, the majority (83.4%) correctly identified the main symptoms of COVID-19. Over 90% had correct knowledge of the incubation period, with lower rates for 18 - 29-year-olds. Knowledge of symptoms and the incubation period varied significantly by population group (p&lt;0.001), dwelling type (p&lt;0.001) and sex (p&lt;0.001). A quarter (24.9%) perceived themselves as at high risk of contracting COVID-19. Risk perception varied by age, population group, employment status and dwelling type (p&lt;0.001). The most prevalent COVID-19 information sources were government sources (72.9%), news websites/apps (56.3%), satellite television (51.6%) and local television (51.4%).

CONCLUSIONS

Understanding knowledge, attitudes and behaviours of people facing the COVID-19 pandemic is crucial for guiding strategic policy. These findings provide public understanding of COVID-19 as the phases of the country-level epidemic progress, and also directly inform communication needs and gaps.

Barriers to the Use of Assistive Technology with Children: A Survey

This article reports on the responses of 120 teachers and habilitative specialists of multiply handicapped blind and deaf-blind children in Massachusetts to a survey on their use of assistive technology. The respondents reported problems in all areas covered by the survey: knowledge of electronic mobility aids and communication devices; the availability, maintenance, and funding of devices; and adequate information about devices. They especially mentioned the need for resources to assess and match students to appropriate devices and to generate more training for themselves.

Feasibility and preliminary effects of a peer-led motivationally-embellished workplace walking intervention: A pilot cluster randomized trial (the START trial)

Walking interventions can be effective in increasing physical activity amongst physically inactive employees. However, despite their promising potential regarding sustainability and scalability, peer-led workplace walking interventions have not been tested. We evaluated a peer-led workplace group walking intervention designed to engage physically inactive employees. A 16-week pilot cluster randomized controlled trial consisted of enhanced (5 worksites; n = 50 participants) and minimal treatment (3 worksites; n = 47) conditions. All participants were provided with a Fitbit Zip and information on health benefits of walking. Enhanced treatment participants had access to a mobile phone app incorporating behavior change techniques, were trained on principles of autonomous motivation, and had a peer leader trained in a motivationally supportive communication style. Feasibility assessments included recruitment and drop-out rates, assessment completion rates, training acceptability (walkers and peer leaders), and intervention acceptability (walkers only). Outcomes assessed included movement-related behaviors (assessed via activPAL devices), cardio-metabolic risk factors, motivation to walk, and well-being, and these measures were taken at baseline and post-intervention. The results supported intervention feasibility. Preliminary efficacy evidence was mixed. Markers of cardio-metabolic risk improved in the enhanced treatment only. Autonomous motivation increased in both conditions. There were no changes in step counts, standing, and sitting time, or well-being. Further fine tuning is needed before a definitive RCT. Australian and New Zealand Clinical Trials Registry: ACTRN12618000807257.

Can comprehensive geriatric assessment be delivered without the need for geriatricians? A formative evaluation in two perioperative surgical settings

INTRODUCTION

the aim of this study was to design an approach to improving care for frail older patients in hospital services where comprehensive geriatric assessment (CGA) was not part of the clinical tradition.

METHODS

the intervention was based on the principles of CGA, using quality improvement methodology to embed care processes. Qualitative methods and coproduction were used to inform development of the intervention, which was directed towards the health care professionals involved in peri-operative/surgical cancer care pathways in two large UK teaching hospitals. A formative, qualitative evaluation was undertaken; data collection and analysis were guided by normalisation process theory.

RESULTS

the clinicians involved agreed to use the toolkit, identifying potential benefits including improved surgical decision making and delivery of interventions pre-operatively. However, sites concluded that pre-operative assessment was not the best place for CGA, and at the end of the 12-month trial, implementation was still nascent. Efforts competed against the dominance of national time-limited targets, and concerns relating to patients' immediate treatment and recovery. Some participants involved in the peri-operative pathway felt that CGA required ongoing specialist input from geriatricians, but it was not clear that this was sustainable.

CONCLUSIONS

clinical toolkits designed to empower non-geriatric teams to deliver CGA were received with initial enthusiasm, but did not fully achieve their stated aims due to the need for an extended period of service development with geriatrician support, competing priorities, and divergent views about appropriate professional domains.

Developing a new quality of life instrument with older people for economic evaluation in aged care: study protocol

INTRODUCTION

The ageing of the population represents a significant challenge for aged care in Australia and in many other countries internationally. In an environment of increasing resource constraints, new methods, techniques and evaluative frameworks are needed to support resource allocation decisions that maximise the quality of life and well-being of older people. Economic evaluation offers a rigorous, systematical and transparent framework for measuring quality and efficiency, but there is currently no composite mechanism for incorporating older people's values into the measurement and valuation of quality of life for quality assessment and economic evaluation. In addition, to date relatively few economic evaluations have been conducted in aged care despite the large potential benefits associated with their application in this sector. This study will generate a new preference based older person-specific quality of life instrument designed for application in economic evaluation and co-created from its inception with older people.

METHODS AND ANALYSIS

A candidate descriptive system for the new instrument will be developed by synthesising the findings from a series of in-depth qualitative interviews with 40 older people currently in receipt of aged care services about the salient factors which make up their quality of life. The candidate descriptive system will be tested for construct validity, practicality and reliability with a new independent sample of older people (n=100). Quality of life state valuation tasks using best worst scaling (a form of discrete choice experiment) will then be undertaken with a representative sample of older people currently receiving aged care services across five Australian states (n=500). A multinomial (conditional) logistical framework will be used to analyse responses and generate a scoring algorithm for the new preference-based instrument.

ETHICS AND DISSEMINATION

The new quality of life instrument will have wide potential applicability in assessing the cost effectiveness of new service innovations and for quality assessment across the spectrum of ageing and aged care. Results will be disseminated in ageing, quality of life research and health economics journals and through professional conferences and policy forums. This study has been reviewed by the Human Research Ethics Committee of the University of South Australia and has ethics approval (Application ID: 201644).

Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study

Background

The aim of this study was to provide high-quality evidence on delivering hospital-wide Comprehensive Geriatric Assessment (CGA).

Objective(s)

(1) To define CGA, its processes, outcomes and costs in the published literature, (2) to identify the processes, outcomes and costs of CGA in existing hospital settings in the UK, (3) to identify the characteristics of the recipients and beneficiaries of CGA in existing hospital settings in the UK and (4) to develop tools that will assist in the implementation of hospital-wide CGA.

Design

Mixed-methods study combining a mapping review, national survey, large data analysis and qualitative methods.

Participants

People aged ≥ 65 years in acute hospital settings.

Data sources

Literature review – Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE and EMBASE. Survey – acute hospital trusts. Large data analyses – (1) people aged ≥ 75 years in 2008 living in Leicester, Nottingham or Southampton (development cohort,n = 22,139); (2) older people admitted for short stay (Nottingham/Leicester,n = 825) to a geriatric ward (Southampton,n = 246) or based in the community (Newcastle,n = 754); (3) people aged ≥ 75 years admitted to acute hospitals in England in 2014–15 (validation study,n = 1,013,590). Toolkit development – multidisciplinary national stakeholder group (co-production); field-testing with cancer/surgical teams in Newcastle/Leicester.

Results

Literature search – common outcomes included clinical, operational and destinational, but not patient-reported, outcome measures. Survey – highly variable provision of multidisciplinary assessment and care across hospitals. Quantitative analyses – in the development cohort, older people with frailty diagnoses formed a distinct group and had higher non-elective hospital use than older people without a frailty diagnosis. Patients with the highest 20% of hospital frailty risk scores had increased odds of 30-day mortality [odds ratio (OR) 1.7], long length of stay (OR 6.0) and 30-day re-admission (OR 1.5). The score had moderate agreement with the Fried and Rockwood scales. Pilot toolkit evaluation – participants across sites were still at the beginning of their work to identify patients and plan change. In particular, competing definitions of the role of geriatricians were evident.

Limitations

The survey was limited by an incomplete response rate but it still provides the largest description of acute hospital care for older people to date. The risk stratification tool is not contemporaneous, although it remains a powerful predictor of patient harms. The toolkit evaluation is still rather nascent and could have meaningfully continued for another year or more.

Conclusions

CGA remains the gold standard approach to improving a range of outcomes for older people in acute hospitals. Older people at risk can be identified using routine hospital data. Toolkits aimed at enhancing the delivery of CGA by non-specialists can be useful but require prolonged geriatrician support and implementation phases. Future work could involve comparing the hospital-based frailty index with the electronic Frailty Index and further testing of the clinical toolkits in specialist services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Exploring the acceptability and usability of a novel social innovation to encourage physical activity: The iStep prototype

This study explored the acceptability and usability of the iStep prototype a novel social innovation to encourage intergenerational physical activity (PA) to help reduce obesity levels in older age. Obesity is a major public health issue and physical inactivity is one of the many factors that influence this, especially in childhood and later life. iStep (a pedometer and interactive website) sought to increase PA levels across the life course through intergenerational partnerships participating in walking challenges together. This was a qualitative mixed methods study involving 130 participants from two different settings. Pupils and teachers from a local secondary school (n = 120) tested the iStep prototype over two separate 2-week periods. Pupil and teacher partnerships engaged in a walking challenge using pedometers and the website platform. In addition, 10 retirement age women were involved in a modified co-operative evaluation of the prototype. Two focus groups with pupils (n = 9 and 20), semistructured interviews with teachers (n = 5), and one dyadic interview (pupil/teacher) were undertaken. Data were analysed using an iterative thematic approach. Five themes were identified: perceptions of the technology, attitudes towards the walking challenge, attitudes to the intergenerational partnership, competition versus collaboration and promoting PA. The pedometer was a useful motivational tool which raised awareness of PA levels. The website was thought to be simple and easy to use. Walking was deemed inclusive and accessible to all age groups and setting a target goal was considered beneficial. Engaging in PA with a partner was regarded as a good way to provide support and encouragement. Overall, this early prototype evaluation showed that iStep has potential to be an innovative and engaging way to encourage increased PA across generations. It may positively contribute towards reducing obesity levels in older age but outcomes that effectively measure this need to be incorporated in any future iStep testing.

Menstrual abnormalities amongst female South African Hajj pilgrims: a cross-sectional study

Introduction: Hajj (pilgrimage), the fifth pillar of Islam, is obligatory for every Muslim, male or female, provided that he/she is physically and financially able to do so, at least once in his/her lifetime. One of the rituals of Hajj requires the absence of menstruation. In the current modern era, many females utilise oral contraception to manipulate their menstrual cycle so that the pilgrim can be menses free during the main rituals of Hajj. However, many such females are at risk of breakthrough bleeding. Very little information has been documented concerning the incidence of menstrual cycle abnormalities amongst female Hajj pilgrims in general and South African pilgrims in particular. This study aims to determine the incidence of menstrual cycle abnormalities amongst South African female Hajj pilgrims and the potential factors that predispose to them.Methods: A cross-sectional descriptive study was conducted amongst South African female pilgrims during the five-day Hajj period. South Africa is usually limited to 5 000 pilgrims annually with a 50:50 gender split. For most of the five days of Hajj, pilgrims, separated by gender, are housed in special tents. Data were collected using an anonymous self-administered questionnaire. The questionnaires were distributed amongst the ladies’ tents in Mina on the last day of Hajj by nursing sisters attached to the South African medical mission. A total of 470 South African female pilgrims participated in the study with 147 excluded as they were either postmenopausal or had had hysterectomies, resulting in a sample size of 323.Results: Of the 318 participants who responded to the question about hormonal menstrual manipulation (HMM), 195 (61%) attempted this and 123 (39%) did not. Of the 308 participants who responded to the question concerning menstrual cycle problems (MCP), 54 (18%) had problems and 254 (82%) did not. Of the 189 participants who attempted HMM and answered the question on MCP, 44/189 (23%) had MCP, whilst 10/108 (9%) of those who did not attempt HMM had MCP. The OR for MCP was 2.97 (CI 1.46–6.04) if HMM was attempted compared with no HMM attempt.Conclusion: Menstrual irregularities occurred more frequently in those who attempt hormonal menstrual manipulation compared with those who do not. Health education on this issue should be integrated into the pre-Hajj classes.

Characterisation of a sub-20 ps temporal resolution pulse dilation photomultiplier tube

A pulse-dilation photomultiplier tube (PD-PMT) with sub-20 ps temporal resolution has been developed for use with γ-ray-sensitive gas Cherenkov detectors at the National Ignition Facility to improve the diagnosis of nuclear fusion burn history and the areal density of the remaining capsule ablator. The pulse-dilation mechanism entails the application of a time-dependent, ramp waveform to a photocathode-mesh structure, introducing a time-dependent photoelectron accelerating potential. The electric field imparts axial velocity dispersion to outgoing photoelectrons. The photoelectron pulse is dilated as it transits a drift region prior to amplification in a microchannel plate and read out with a digital oscilloscope. We report the first measurements with the prototype PD-PMT demonstrating nominal <20 ps FWHM across a 400 ps measurement window and <30 ps FWHM for an extracted charge up to 300 pC. The output peak areas are linear to within 20% over 3 orders of magnitude of input intensity. 3D particle in cell simulations, which included space charge effects, have been carried out to investigate the device temporal magnification, resolution, and linearity.

Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational study

BACKGROUND

Older people are increasing users of health care globally. We aimed to establish whether older people with characteristics of frailty and who are at risk of adverse health-care outcomes could be identified using routinely collected data.

METHODS

A three-step approach was used to develop and validate a Hospital Frailty Risk Score from International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnostic codes. First, we carried out a cluster analysis to identify a group of older people (≥75 years) admitted to hospital who had high resource use and diagnoses associated with frailty. Second, we created a Hospital Frailty Risk Score based on ICD-10 codes that characterised this group. Third, in separate cohorts, we tested how well the score predicted adverse outcomes and whether it identified similar groups as other frailty tools.

FINDINGS

In the development cohort (n=22 139), older people with frailty diagnoses formed a distinct group and had higher non-elective hospital use (33·6 bed-days over 2 years compared with 23·0 bed-days for the group with the next highest number of bed-days). In the national validation cohort (n=1 013 590), compared with the 429 762 (42·4%) patients with the lowest risk scores, the 202 718 (20·0%) patients with the highest Hospital Frailty Risk Scores had increased odds of 30-day mortality (odds ratio 1·71, 95% CI 1·68-1·75), long hospital stay (6·03, 5·92-6·10), and 30-day readmission (1·48, 1·46-1·50). The c statistics (ie, model discrimination) between individuals for these three outcomes were 0·60, 0·68, and 0·56, respectively. The Hospital Frailty Risk Score showed fair overlap with dichotomised Fried and Rockwood scales (kappa scores 0·22, 95% CI 0·15-0·30 and 0·30, 0·22-0·38, respectively) and moderate agreement with the Rockwood Frailty Index (Pearson's correlation coefficient 0·41, 95% CI 0·38-0·47).

INTERPRETATION

The Hospital Frailty Risk Score provides hospitals and health systems with a low-cost, systematic way to screen for frailty and identify a group of patients who are at greater risk of adverse outcomes and for whom a frailty-attuned approach might be useful.

FUNDING

National Institute for Health Research.

Use of primary care and other healthcare services between age 85 and 90 years: longitudinal analysis of a single-year birth cohort, the Newcastle 85+ study

OBJECTIVE

To describe, using data from the Newcastle 85+ cohort study, the use of primary care and other healthcare services by 85-year-olds as they age.

DESIGN

Longitudinal population-based cohort study.

SETTING

Newcastle on Tyne and North Tyneside, UK.

PARTICIPANTS

Community dwelling and institutionalised men and women recruited through general practices (n=845, 319 men and 526 women).

RESULTS

Contact was established with 97% (n=1409/1459) of eligible 85-year-olds, consent obtained from 74% (n=1042/1409) and 851 agreed to undergo the multidimensional health assessment and a general practice medical records review. A total of 845 participants had complete data at baseline for this study (319 male, 526 female), with 344 (118 male, 226 female) reinterviewed at 60 months. After adjusting for confounders, all consultations significantly increased over the 5 years (incidence rate ratio, IRR=1.03, 95% CI 1.01 to 1.05, P=0.001) as did general practitioner (GP) consultations (IRR=1.03, 95% CI 1.01 to 1.05, P=0.006). Significant increases were also observed in inpatient and day hospital use over time, though these disappeared after adjustment for confounders.

CONCLUSIONS

Our study of primary, secondary and community care use by the very old reveals that, between the ages of 85 and 90 years, older people are much more likely to consult their GP than any other primary healthcare team members. With a rapidly ageing society, it is essential that both current and future GPs are appropriately skilled, and adequately supported by specialist colleagues, as the main healthcare provider for a population with complex and challenging needs.

Effect of the carbon dioxide 10,600-nm laser and topical fluoride gel application on enamel microstructure and microhardness after acid challenge: an in vitro study

The aim of this in-vitro study was to evaluate positive effects of the carbon dioxide laser (CO₂, 10,600 nm) with acidulated phosphate fluoride (APF) gel on enamel acid resistance. Twenty extracted human third molars (40 surfaces) were randomly assigned into four groups: group C, untreated control; group L, CO₂ laser alone group; group F, APF 1.23% fluoride gel; and group FL, APF 1.23% gel and laser. Samples from group L were irradiated with a CO₂ laser for 30s. The parameter settings used were average power, 0.73 W; time on, 100 μs; time off, 40 ms; tip-to-tissue distance, 20 mm; tip diameter 700 μm; and energy density with movements, 5 J/cm². Samples from group F were treated with the APF gel for 4 min, and the gel was washed off with distilled water. The enamel samples from group FL were treated with APF gel for 4 min and then irradiated with the CO₂ laser for 30s without removing the gel. Each enamel sample was placed in 50 ml soft drink (pH = 2.75) for 10 min then rinsed with deionized water and stored in artificial saliva at 37 °C for 1 h. Samples were assessed for Vickers hardness number (VHN) before and after treatments and subjected to SEM analysis. Data were analyzed using a one-way analysis of variance (ANOVA) and Tukey's test (α < 0.05). After the acid challenge, the untreated C group was demineralized to a great extent and the enamel surface was with the lowest mean score of microhardness. The observed VHN in the control (C group) had a mean value of 176.13, the scores in the CO₂ laser group (L group) were with mean value of 238.40, the F group with a mean value of 218.45, and the fluoride-treated and laser-irradiated FL group-with a mean of 268.28 VHN. Paired t test performed to compare groups C, L, F, and FL has shown that group FL has greater resistance to decrease in microhardness of dental enamel (P ≤ 0.05) on exposure to acidic protocol. After the acid challenge, the fluoride-treated and laser-irradiated samples (group FL) showed the least diminution in enamel surface microhardness. The sub-ablative carbon dioxide laser irradiation in combination with fluoride treatment is more effective in protecting enamel surface and resisting demineralization than CO₂ laser irradiation or fluoride alone.

New horizons in multimorbidity in older adults

The concept of multimorbidity has attracted growing interest over recent years, and more latterly with the publication of specific guidelines on multimorbidity by the National Institute for Health and Care Excellence (NICE). Increasingly it is recognised that this is of particular relevance to practitioners caring for older adults, where multimorbidity may be more complex due to the overlap of physical and mental health disorders, frailty and polypharmacy. The overlap of frailty and multimorbidity in particular is likely to be due to the widespread health deficit accumulation, leading in some cases to functional impairment. The NICE guidelines identify 'target groups' who may benefit from a tailored approach to care that takes their multimorbidity into account, and make a number of research recommendations. Management includes a proactive individualised assessment and care plan, which improves quality of life by reducing treatment burden, adverse events, and unplanned or uncoordinated care.

Opportunity for interprofessional collaborative care-findings from a sample of federally qualified health center patients in the Midwest

OBJECTIVES

Federally qualified health centers (FQHCs) frequently serve more socio-economically disadvantaged populations; existing literature suggests that underserved groups are more likely to experience various chronic physical and mental health conditions. FQHC patients may have significant needs for various specialty services that are beyond common FQHC providers. This study examines chronic condition prevalence, healthcare satisfaction, and use of multiprovider services in a Midwest FQHC patient population. We also evaluated the potential of interprofessional collaborative practices in FQHC settings.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 232 participants were recruited prior to or immediately after their scheduled clinic visit within an FQHC located on the fringes of an urban area. Respondents were invited to complete a brief questionnaire and grant access to their electronic medical records.

RESULTS

Nearly half of participants were covered by Medicaid, private insurance carriers (19.4%), or Medicare (17.7%). The most prevalent chronic conditions included diabetes, depression, anxiety, and chronic pain. Almost half (46.6%) of participants were seen by two or three providers; 20% had 7+ office visits in the last year. While 35.3% reported health dissatisfaction, 30.6% reported health satisfaction. When asked if they were satisfied with their health care, nearly 70% reported satisfaction with health care, while only 4.7% reported healthcare dissatisfaction.

CONCLUSIONS

The authors of this study recommend an interprofessional collaborate healthcare model be explored to address the complex and multifaceted healthcare needs of this population. Future research in this area should prospectively examine the utility of monitoring patient satisfaction in a collaborative practice setting.

Management practices associated with pain in cattle on western Canadian cow-calf operations: A mixed methods study

The implementation of on-farm pain mitigation strategies is dependent on feasibility and importance to producers. Currently, there is a lack of information regarding adoption of management practices associated with pain in cattle within the Canadian beef industry. The objective of this mixed methods study was to describe pain-associated practices implemented on farm and producer perceptions toward pain mitigation strategies. A questionnaire about calving management and calf processing was delivered to 109 cow-calf producers in western Canada. In addition, 15 respondents were purposively selected based on questionnaire responses to participate in individual semistructured, on-farm interviews. The prevalence of pain mitigation strategies used for dystocia and cesarean section by respondents were 46 and 100%, respectively. The majority of operations reported castrating and dehorning calves before 3 mo of age (95 and 89%, respectively). The majority of operations did not use pain mitigation strategies for castration and dehorning (90 and 85%, respectively). Branding was practiced by 57% of respondents, 4% of which used pain mitigation. Thematic content analysis revealed that producers' perception of pain were influenced by what they referred to as "common sense," relatability to cattle, visual evidence of pain, and age of the animal. Factors that influenced participant rationale for the implementation of pain mitigation practices included access to information and resources, age of the animal, benefit to the operation, cost and logistics, market demands, and personal conscience. Overall, management practices were generally in compliance with published Canadian guidelines. Results of this study may provide direction for future policy making, research, and extension efforts to encourage the adoption of pain mitigation strategies.

Inadequate pelvic radiographs: implications of not getting it right the first time

Introduction Pelvic radiography is a frequent investigation. European guidelines aim to ensure appropriate use and adequate quality. When initial images are inadequate, repeat radiographs are often required, which may have significant patient safety and economic implications. Objectives The study aimed to assess the adequacy of pelvic imaging across three orthopaedic centres, to identify causes for inadequate imaging and to establish the cost of inadequate imaging from financial and patient safety perspectives. Methods Pelvic radiographs were identified on Picture Archiving and Communication System software at three UK hospitals. Radiographs were assessed against European guidelines and indications for repeat imaging were analysed. Results A total of 1,531 sequential pelvic radiographs were reviewed. The mean age of patients was 60 years (range 5 months to 101 years). Of this total, 51.9% of images were suboptimal, with no significant difference across the three hospitals (P > 0.05). Hospital 3 repeated radiographs in 6.3% of cases, compare with 18.1% and 19.7% at hospitals 1 and 2, respectively (P > 0.05). Hospital 3 identified pathology missed on the initial radiograph in 1% of cases, compared with 5.4% and 5.5% at hospitals 1 and 2, respectively (P > 0.05). Out-of-hours imaging is associated with a higher rate of suboptimal quality (69.1%) compared with normal working hours (51.3%; P = 0.006). Adequacy rates vary with age (χ ² = 43.62, P < 0.001). Risk of having a suboptimal radiograph increases above the age of 60-years (χ ² = 4.45, P < 0.05). The annual cost of repeat radiographs was £56,200 per hospital. Discussion and conclusion High rates of pelvic radiograph inadequacy can lead to missed pathology and the requirement for repeat imaging, which has significant patient safety and financial implications. Risk factors for inadequate radiographs include older patients and those having out-of-hours imaging.

Acute geriatrics at the front door

Older people with frailty and urgent care needs are major uses of health and social care services. Comprehensive geriatric assessment (CGA) is an evidence-based approach to improving their outcomes, as well as improving service outcomes. Geriatricians form a small proportion of the overall workforce and cannot address the population need alone, so all clinicians (doctors, nurses, therapists and so on) need to engage in delivering CGA as a process of care, underpinned by specific competencies - which can be developed. Delivery of this care pathway needs to be measured and improved as rigorously as campaigns like those for improving sepsis or eradicating methicillin-resistant Staphylococcus aureus.

Management practices associated with stress in cattle on western Canadian cow-calf operations: A mixed methods study

Handling, weaning, and euthanasia are some of the most stressful practices performed on cow-calf operations. Although strategies to minimize stress exist, their use on western Canadian cow-calf operations is unknown. The objectives were to describe current stress-associated practices on western Canadian cow-calf operations, describe producer and operation demographics associated with the use of nonabrupt weaning methods, and explore producer perceptions toward these practices. A questionnaire focusing on stressful management practices was delivered to 109 cow-calf producers in western Canada. Fifteen respondents were purposively selected for individual interviews. The majority of producers reported calves less than 1 wk of age were handled by manual restraint (87%) and those older than 1 wk of age were handled using a cattle squeeze or table. Most producers performed abrupt weaning (70%). Interviewees often mentioned that cost and logistics were major factors in deciding on a weaning strategy. Pasture availability and facilities were viewed as constraints toward the adoption of a nonabrupt weaning method. Animal stress was considered, as producers expressed concern that nonabrupt weaning methods may cause increased stress because of the additional handling required. Producers conveyed that animal age was a major factor that impacted weaning stress and that improved animal performance might motivate them to adopt a nonabrupt weaning strategy. Producers also expressed reluctance to change previously successful traditional approaches. Of respondents, 13% did not euthanize cattle on farm and 8% did not confirm death. Producers interviewed reported that the decision to euthanize cattle on farm was difficult and that veterinary advice was often considered. Factors that influenced their decision to euthanize included the animal's likelihood of recovery and degree of pain and distress. Finally, producers explained that they considered whether the animal was salvageable and able to be transported. Identification of common methods of handling provides focus for future research to determine optimal handling strategies. Identified barriers to nonabrupt weaning may be addressed through research, extension, or policy to encourage the adoption of weaning methods that could improve animal welfare. Confirmation of death after euthanasia was identified as an area that needs to be addressed by producer education to minimize animal stress during on-farm euthanasia.

Protocol for the Delirium and Cognitive Impact in Dementia (DECIDE) study: A nested prospective longitudinal cohort study

BACKGROUND

Delirium is common, affecting at least 20% of older hospital inpatients. It is widely accepted that delirium is associated with dementia but the degree of causation within this relationship is unclear. Previous studies have been limited by incomplete ascertainment of baseline cognition or a lack of prospective delirium assessments. There is an urgent need for an improved understanding of the relationship between delirium and dementia given that delirium prevention may plausibly impact upon dementia prevention. A well-designed, observational study could also answer fundamental questions of major importance to patients and their families regarding outcomes after delirium. The Delirium and Cognitive Impact in Dementia (DECIDE) study aims to explore the association between delirium and cognitive function over time in older participants. In an existing population based cohort aged 65 years and older, the effect on cognition of an episode of delirium will be measured, independent of baseline cognition and illness severity. The predictive value of clinical parameters including delirium severity, baseline cognition and delirium subtype on cognitive outcomes following an episode of delirium will also be explored.

METHODS

Over a 12 month period, surviving participants from the Cognitive Function and Ageing Study II-Newcastle will be screened for delirium on admission to hospital. At the point of presentation, baseline characteristics along with a number of disease relevant clinical parameters will be recorded. The progression/resolution of delirium will be monitored. In those with and without delirium, cognitive decline and dementia will be assessed at one year follow-up. We will evaluate the effect of delirium on cognitive function over time along with the predictive value of clinical parameters.

DISCUSSION

This study will be the first to prospectively elucidate the size of the effect of delirium upon cognitive decline and incident dementia. The results will be used to inform future dementia prevention trials that focus on delirium intervention.

A review of a pleural service

This paper reviews the organisation and outcomes of a pleural service, specifically geared towards the management of malignant pleural effusions, in a district general hospital in the north east of England. We summarise the evidence behind local anaesthetic thoracoscopy and indwelling pleural catheters. We then summarise the review of our service, including a discussion around complications.

Calibration with confidence: a principled method for panel assessment

Frequently, a set of objects has to be evaluated by a panel of assessors, but not every object is assessed by every assessor. A problem facing such panels is how to take into account different standards among panel members and varying levels of confidence in their scores. Here, a mathematically based algorithm is developed to calibrate the scores of such assessors, addressing both of these issues. The algorithm is based on the connectivity of the graph of assessors and objects evaluated, incorporating declared confidences as weights on its edges. If the graph is sufficiently well connected, relative standards can be inferred by comparing how assessors rate objects they assess in common, weighted by the levels of confidence of each assessment. By removing these biases, 'true' values are inferred for all the objects. Reliability estimates for the resulting values are obtained. The algorithm is tested in two case studies: one by computer simulation and another based on realistic evaluation data. The process is compared to the simple averaging procedure in widespread use, and to Fisher's additive incomplete block analysis. It is anticipated that the algorithm will prove useful in a wide variety of situations such as evaluation of the quality of research submitted to national assessment exercises; appraisal of grant proposals submitted to funding panels; ranking of job applicants; and judgement of performances on degree courses wherein candidates can choose from lists of options.