Transitional chelal digit patterns in saprophagous astigmatan mites.

Changes in the functional shape of astigmatan mite moveable digit profiles are examined to test if Tyrophagus putrescentiae (Acaridae) is a trophic intermediate between a typical micro-saprophagous carpoglyphid (Carpoglyphus lactis) and a common macro-saprophagous glycyphagid (Glycyphagus domesticus). Digit tip elongation in these mites is decoupled from the basic physics of optimising moveable digit inertia. Investment in the basal ramus/coronoid process compared to that for the moveable digit mastication length varies with feeding style. A differentiated ascending ramus is indicated in C. lactis and in T. putrescentiae for different trophic reasons. Culturing affects relative investments in C. lactis. A markedly different style of feeding is inferred for the carpoglyphid. The micro-saprophagous acarid does not have an intermediate pattern of trophic functional form between the other two species. Mastication surface shape complexity confirms the acarid to be heterodontous. T. putrescentiae is a particularly variably formed species trophically. A plausible evolutionary path for the gradation of forms is illustrated. Digit form and strengthening to resist bending under occlusive loads is explored in detail. Extensions to the analytical approach are suggested to confirm the decoupling of moveable digit pattern from cheliceral and chelal adaptations. Caution is expressed when interpreting ordinations of multidimensional data in mites.

Do astigmatid teeth matter: a tribological review of cheliceral chelae in co-occuring mites from UK beehives.

The dentition of the chelal moveable digit in cohabiting astigmatids from UK beehives (i.e., Carpoglyphus lactis (Linnaeus), Glycyphagus domesticus (DeGeer), and Tyrophagus putrescentiae (Schrank)) is characterised for the first time using quantitative tribological measures within a 2D mechanical model. The trophic function of astigmatid chelae are reviewed in terms of macroscopic tools used by humans including hooking devices, pliers, shears, rasps and saws. Comparisons to oribatid claws and isopod dactyli are made. The overall pattern of the moveable digit form of T. putrescentiae is not just a uniformly shrunken/swollen version between the other two taxa at either the macro- or micro-scale. Mastication surface macro-roughness values are in the range of international Roughness Grade Numbers N5-N6. The moveable digit of C. lactis has low rugosity values compared to the glycyphagid and acarid (which are topographically more similar and match that roughness typical of some coral reef surfaces). C. lactis has the most plesiomorphic moveable digit form. The mastication surface of all three species as a chewing tool is distinctly ornamented despite the moveable digit of C. lactis looking like a bar-like beam. The latter has more opportunities to be a multifunctional tool behaviourally than the other two species. Little evidence of any differences in the 'spikiness' of any 'toothiness' is found. Some differences with laboratory cultured specimens are found in C. lactis and possibly T. putrescentiae suggesting where selection on the digit may be able to occur. The chelal surface of T. putrescentiae has been deformed morphologically during evolution the most, that of C. lactis the least. Repeated localised surface differentiation is a feature of the moveable digit in G. domesticus compared to the likely more concerted changes over certain nearby locations in T. putrescentiae. An impactful chelal teeth design is present in G. domesticus but this is more equivocal in T. putrescentiae. Pockets within the mastication surface of the glycyphagid (and to some extent for the acarid) may produce foodstuff crunch forces of the scale of the chelal tips of oribatids. The moveable digit dentition of G. domesticus is adapted to shred foodstuff (like a ripsaw) more than that of the grazing/shearing dentition of T. putrescentiae. The collecting 'picker' design of C. lactis posterior teeth matches the size of Bettsia alvei hyphae which attacks hive-stored pollen. Detritus accumulated in chelal digit gullets through a sawing action matches the smallest observed ingested material. The dentition of C. lactis should produce less friction when moving through food material than G. domesticus. C. lactis is the most hypocarnivorous and may 'skim' through fluids when feeding. Astigmatid teeth do matter. The three commensal species can avoid direct competition. Future work is proposed in detail.

Looking for future biological control agents: the comparative function of the deutosternal groove in mesostigmatid mites.

The physics of fluid laminar flow through an idealised deutosternum assembly is used for the first time to review predatory feeding designs over 72 different-sized example species from 16 mesostigmatid families in order to inform the finding of new biological control agents. Gnathosomal data are digitised from published sources. Relevant gnathosomal macro- and micro-features are compared and contrasted in detail which may subtly impact the control of channel- or 'pipe'-based transport of prey liquids around various gnathosomal locations. Relative deutosternal groove width on the mesostigmatid subcapitulum is important but appears unrelated to the closing velocity ratio of the moveable digit. Big mites are adapted for handling large and watery prey. The repeated regular distance between deutosternal transverse ridges ('Querleisten') supports the idea of them enabling a regular fluctuating bulging or pulsing droplet-based fluid wave 'sticking' and 'slipping' along the groove. Phytoseiids are an outlier functional group with a low deutosternal pipe flow per body size designed for slot-like microchannel transport in low volume fluid threads arising from daintily nibbling nearby prey klinorhynchidly. Deutosternal groove denticles are orientated topographically in order to synergise flow and possible mixing of coxal gland-derived droplets and circumcapitular reservoir fluids across the venter of the gnathosomal base back via the hypostome to the prey being masticated by the chelicerae. As well as working with the tritosternum to mechanically clean the deutosternum, denticles may suppress fluid drag. Shallow grooves may support edge-crawling viscous flow. Lateral features may facilitate handling unusual amounts of fluid arising from opportunistic feeding on atypical prey. Various conjectures for confirmatory follow-up are highlighted. Suggestions as to how to triage non-uropodoid species as candidate plant pest control agents are included.

Feeding design in free-living mesostigmatid chelicerae (Acari: Anactinotrichida).

A model based upon mechanics is used in a re-analysis of historical acarine morphological work augmented by an extra seven zoophagous mesostigmatid species. This review shows that predatory mesostigmatids do have cheliceral designs with clear rational purposes. Almost invariably within an overall body size class, the switch in predatory style from a worm-like prey feeding ('crushing/mashing' kill) functional group to a micro-arthropod feeding ('active prey cutting/slicing/slashing' kill) functional group is matched by: an increased cheliceral reach, a bigger chelal gape, a larger morphologically estimated chelal crunch force, and a drop in the adductive lever arm velocity ratio of the chela. Small size matters. Several uropodines (Eviphis ostrinus, the omnivore Trachytes aegrota, Urodiaspis tecta and, Uropoda orbicularis) have more elongate chelicerae (greater reach) than their chelal gape would suggest, even allowing for allometry across mesostigmatids. They may be: plesiosaur-like high-speed strikers of prey, scavenging carrion feeders (like long-necked vultures), probing/burrowing crevice feeders of cryptic nematodes, or small morsel/fragmentary food feeders. Some uropodoids have chelicerae and chelae which probably work like a construction-site mechanical excavator-digger with its small bucket. Possible hoeing/bulldozing, spore-cracking and tiny sabre-tooth cat-like striking actions are discussed for others. Subtle changes lead small mesostigmatids to be predator-scavengers (mesocarnivores) or to be predator-fungivores (hypocarnivores). Some uropodines (e.g., the worm-like prey feeder Alliphis siculus and, Uropoda orbicularis) show chelae similar in design to astigmatids and cryptostigmatids indicating possible facultative saprophagy. Scale matters-obligate predatory designs (hypercarnivory) start for mesostigmatids with chelal gape > 150 µm and cheliceral reach > 350 µm (i.e., about 500-650 µm in body size). Commonality of trophic design in these larger species with solifugids is indicated. Veigaia species with low chelal velocity ratio and other morphological strengthening specialisms, appear specially adapted in a concerted way for predating active soft and fast moving springtails (Collembola). Veigaia cerva shows a markedly bigger chelal gape than its cheliceral reach would proportionately infer suggesting it is a crocodile-like sit-and-wait or ambush predator par excellence. A small chelal gape, low cheliceral reach, moderate velocity ratio variant of the worm-like feeding habit design is supported for phytoseiid pollenophagy. Evidence for a resource partitioning model in the evolution of gnathosomal development is found. A comparison to crustacean claws and vertebrate mandibles is made. Alliphis siculus and Rhodacarus strenzkei are surprisingly powerful mega-cephalics for their small size. Parasitids show a canid-like trophic design. The chelicera of the nematophagous Alliphis halleri shows felid-like features. Glyphtholaspis confusa has hyaena-like cheliceral dentition. The latter species has a markedly smaller chelal gape than its cheliceral reach would suggest proportionately, which together with a high chelal velocity ratio and a high estimated chelal crunch force matches a power specialism of feeding on immobile tough fly eggs/pupae by crushing (durophagy). A consideration of gnathosomal orientation is made. Predatory specialisms appear to often match genera especially in larger mesostigmatids, which may scale quite differently. Comparison to holothyrids and opilioacarids indicates that the cheliceral chelae of the former are cutting-style and those of the latter are crushing-style. A simple validated easy-to-use '2:1 on' predictive algorithm of feeding habit type is included based on a strength-speed tradeoff in chelal velocity ratio for ecologists to test in the field.

Cheliceral chelal design in free-living astigmatid mites.

Cheliceral chelal design in free-living astigmatid mites (Arthropoda: Acari) is reviewed within a mechanical model. Trophic access (body size and cheliceral reach) and food morsel handling (chelal gape and estimated static adductive crushing force) are morphologically investigated. Forty-seven commonly occurring astigmatid mite species from 20 genera (covering the Acaridae, Aeroglyphidae, Carpoglyphidae, Chortoglyphidae, Glycyphagidae, Lardoglyphidae, Pyroglyphidae, Suidasiidae, and Winterschmidtiidae) are categorised into functional groups using heuristics. Conclusions are confirmed with statistical tests and multivariate morphometrics. Despite these saprophagous acarines in general being simple 'shrunken/swollen' versions of each other, clear statistical correlations in the specifics of their mechanical design (cheliceral and chelal scale and general shape) with the type of habitat and food consumed (their 'biome') are found. Using multivariate analyses, macro- and microsaprophagous subtypes are delineated. Relative ratios of sizes on their own are not highly informative of adaptive syndromes. Sympatric resource competition is examined. Evidence for a maximum doubling of approximate body volume within nominal taxa is detected but larger mites are not more 'generalist' feeding types. Two contrasting types of basic 'Bauplan' are found differing in general scale: (i) a large, chunk-crunching, 'demolition'-feeding omnivore design (comprising 10 macrosaprophagous astigmatid species), and (ii) a small selective picking, squashing/slicing or fragmentary/'plankton' feeding design (which may indicate obligate fungivory/microbivory) comprising 20 microsaprophagous acarid-shaped species. Seventeen other species appear to be specialists. Eleven of these are either: small (interstitial/burrowing) omnivores-or a derived form designed for processing large hard food morsels (debris durophagy, typified by the pyroglyphid Dermatophagoides farinae), or a specialist sub-type of particular surface gleaning/scraping fragmentary feeding. Six possible other minor specialist gleaning/scraping fragmentary feeders types each comprising one to two species are described. Details of these astigmatid trophic-processing functional groups need field validation and more corroborative comparative enzymology. Chelal velocity ratio in itself is not highly predictive of habitat but with cheliceral aspect ratio (or chelal adductive force) is indicative of life-style. Herbivores and pest species are typified by a predicted large chelal adductive force. Pest species may be 'shredders' derived from protein-seeking necrophages. Carpoglyphus lactis typifies a mite with tweezer-like chelae of very feeble adductive force. It is suggested that possible zoophagy (hypocarnivory) is associated with low chelal adductive force together with a small or large gape depending upon the size of the nematode being consumed. Kuzinia laevis typifies an oophagous durophage. Functional form is correlated with taxonomic position within the Astigmata-pyroglyphids and glycyphagids being distinct from acarids. A synthesis with mesostigmatid and oribatid feeding types is offered together with clarification of terminologies. The chelal lyrifissure in the daintiest chelicerae of these astigmatids is located similar to where the action of the chelal moveable digit folds the cheliceral shaft in uropodoids, suggesting mechanical similarities of function. Acarid astigmatids are trophically structured like microphytophagous/fragmentary feeding oribatids. Some larger astigmatids (Aleuroglyphus ovatus, Kuzinia laevis, Tyroborus lini) approximate, and Neosuidasia sp. matches, the design of macrophytophagous oribatids. Most astigmatid species reviewed appear to be positioned with other oribatid secondary decomposers. Only Dermatophagoides microceras might be a primary decomposer approximating a lichenivorous oribatid (Austrachipteria sp.) in trophic form. Astigmatid differences are consilient with the morphological trend from micro- to macrophytophagy in oribatids. The key competency in these actinotrichid mites is a type of 'gnathosomisation' through increased chelal and cheliceral height (i.e., a shape change that adjusts the chelal input effort arm and input adductive force) unrestricted by the dorsal constraint of a mesostigmatid-like gnathotectum. A predictive nomogram for ecologists to use on field samples is included. Future work is proposed in detail.

The gut epithelium from feeding to fasting in the predatory soil mite Pergamasus longicornis (Mesostigmata: Parasitidae): one tissue, two roles.

A review of acarine gut physiology based on published narratives dispersed over the historical international literature is given. Then, in an experimental study of the free-living predatory soil mite Pergamasus longicornis (Berlese), quantitative micro-anatomical changes in the gut epithelium are critically assessed from a temporal series of histological sections during and after feeding on larval dipteran prey. An argued functional synthesis based upon comparative kinetics is offered for verification in other mesostigmatids. Mid- and hind-gut epithelia cell types interconvert in a rational way dependent upon the physical consequences of ingestion, absorption and egestion. The fasted transitional pseudo-stratified epithelium rapidly becomes first squamous on prey ingestion (by stretching), then columnar during digestion before confirmed partial disintegration (gut 'lumenation') during egestion back to a pseudo-stratified state. Exponential processes within the mid- and endodermic hind-gut exhibit 'stiff' dynamics. Cells expand rapidly ([Formula: see text] 22.9-49.5 min) and vacuolate quickly ([Formula: see text] 1.1 h). Cells shrink very slowly ([Formula: see text] 4.9 days) and devacuolate gently ([Formula: see text] 1.0-1.7 days). Egestive cellular degeneration has an initial [Formula: see text] 7.7 h. Digestion appears to be triggered by maximum gut expansion-estimated at 10 min post start of feeding. Synchrony with changes in gut lumen contents suggests common changes in physiological function over time for the cells as a whole tightly-coupled epithelium. Distinct in architecture as a tissue over time the various constituent cell types appear functionally the same. Functional phases are: early fluid transportation (0-1 h) and extracellular activity (10-90 min); through rising food absorption (10 min to [Formula: see text] day); to slow intracellular meal processing and degenerative egestive waste material production (1 to [Formula: see text] days) much as in ticks. The same epithelium is both absorptive and degenerative in role. The switch in predominant physiology begins 4 h after the start of feeding. Two separate pulses of clavate cells appear to be a mechanism to facilitate transport by increasing epithelial surface area in contact with the lumen. Free-floating cells may augment early extracellular lumenal digestion. Possible evidence for salivary enzyme alkaline-related extra-corporeal digestion was found. Giant mycetome-like cells were found embedded in the mid-gut wall. Anteriorly, the mid-gut behaves like a temporally expendable food processing tissue and minor long-term resistive store. Posteriorly the mid-gut behaves like a major assimilative/catabolic tissue and 'last-out' food depot (i.e., a 'hepatopancreas' function) allowing the mite to resist starvation for up to 3.5 weeks after a single meal. A 'conveyor-belt' wave of physiology (i.e., feeding and digestion, then egestion and excretion) sweeps posteriorly but not necessarily pygidially over time. Assimilation efficiency is estimated at 82%. The total feeding cycle time histologically from a single meal allowing for the bulk of intracellular digestion and egestive release is not 52.5 h but of the order of 6 days ([Formula: see text] total gut emptyings per day), plus typically a further 3 days for subsequent excretion to occur. Final complete gut system clearance in this cryptozooid may take much longer ([Formula: see text] days). A common physiology across the anactinotrichid acarines is proposed. A look to the future of this field is included.

Optimal healthcare delivery to care homes in the UK: a realist evaluation of what supports effective working to improve healthcare outcomes.

INTRODUCTION: care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use. METHODS: a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners. RESULTS: context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which 'wraps around' care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites. CONCLUSION: activities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.

Gut contents, digestive half-lives and feeding state prediction in the soil predatory mite Pergamasus longicornis (Mesostigmata: Parasitidae).

Mid- and hind-gut lumenal changes are described in the free-living predatory soil mite Pergamasus longicornis (Berlese) from a time series of histological sections scored during and after feeding on fly larval prey. Three distinct types of tangible material are found in the lumen. Bayesian estimation of the change points in the states of the gut lumenal contents over time is made using a time-homogenous first order Markov model. Exponential processes within the gut exhibit 'stiff' dynamics. A lumen is present throughout the midgut from 5 min after the start of feeding as the gut rapidly expands. It peaks at about 21.5 h-1.5 days and persists post-feeding (even when the gut is contracted) up until fasting/starvation commences 10 days post start of feeding. The disappearance of the lumen commences 144 h after the start of feeding. Complete disappearance of the gut lumen may take 5-9 weeks from feeding commencing. Clear watery prey material arrives up to 10 min from the start of feeding, driving gut lumen expansion. Intracellular digestion triggered by maximum gut expansion is indicated. Detectable granular prey material appears in the lumen during the concentrative phase of coxal droplet production and, despite a noticeable collapse around 12 h, lasts in part for 52.5 h. Posterior midgut regions differ slightly from anterior regions in their main prey food dynamics being somewhat faster in processing yet being slightly delayed. Posterior regions are confirmed as Last-In-Last-Out depots, anterior regions confirmed as First-In-First-Out conveyor belt processes. Evidence for differential lability of prey fractions is found. A scheme is presented of granular imbibed prey material being first initially rapidly absorbed ([Formula: see text] = 23 min), and also being quickly partly converted to globular material extra-corporeally/extracellularly ([Formula: see text] = 36 min)-which then rapidly disappears ([Formula: see text] = 1.1 h, from a peak around 4 h). This is then followed by slow intracellular digestion ([Formula: see text] = 6.9 h) of the resultant resistant prey residue matching the slow rate of appearance of opaque pre-excretory egestive refractive grains (overall [Formula: see text] = 4.5 days). The latter confirmed latent 'catabolic fraction' (along with Malpighian tubule produced guanine crystals) drives rectal vesicle expansion as 'faeces' during the later phases of gut emptying/contraction. Catabolic half-lives are of the order of 6.3-7.8 h. Membraneous material is only present in the lumen of the gut in starving mites. No obvious peritrophic membrane was observed. The total feeding cycle time may be slightly over 52.5 h. Full clearance in the gut system of a single meal including egestive and excretory products may take up to 3 weeks. Independent corroborative photographs are included and with posterior predictive densities confirm the physiological sequence of ingestion/digestion, egestion, excretion, defecation, together with their timings. Visually dark midguts almost certainly indicate egestive refractive grains (xanthine?) production. Nomograms to diagnose the feeding state of P. longicornis in field samples are presented and show that the timing of these four phases in the wild could be inferred by scoring 10-12 mites out of a sample of 20. Suggestions to critically confirm or refute the conclusions are included.

Modelling Malpighian tubule crystals within the predatory soil mite Pergamasus longicornis (Mesostigmata: Parasitidae).

The occurrence of refractive crystals (aka guanine) is characterised in the Malpighian tubules of the free-living predatory parasitiform soil mite Pergamasus longicornis (Berlese) from a temporal series of histological sections during and after feeding on larval dipteran prey. The tubular system behaves as a single uniform entity during digestion. Malpighian mechanisms are not the 'concentrative' mechanism sought for the early stasis in gut size during the second later phase of prey feeding. Nor are Malpighian changes associated with the time of 'anal dabbing' during feeding. Peak gut expansion precedes peak Malpighian tubule guanine crystal occurrence in a hysteretic manner. There is no evidence of Malpighian tubule expansion by fluid alone. Crystals are not found during the slow phase of liquidised prey digestion. Malpighian tubules do not appear to be osmoregulatory. Malpighian guanine is only observed 48 h to 10 days after the commencement of feeding. Post digestion guanine crystal levels in the expanded Malpighian tubules are high-peaking as a pulse 5 days after the start of feeding (i.e. after the gut is void of food at 52.5 h). The half-life of guanine elimination from the tubules is 53 h. Evidence for a physiological input cascade is found-the effective half-life of guanine appearance in the Malpighian tubules being 7.8-16.7 h. Crystals are found present at all times in the lumen of the rectal vesicle and not anywhere else lumenally in the gut at all. No guanine was observed inside gut cells. There is no evidence for the storage in the rectal vesicle of a 'pulse' of Malpighian excretory products from a discrete 'pulse' of prey ingestion. A latent egestive common catabolic phase in the gut is inferred commencing 12.5 h after the start of feeding which may cause the rectal vesicle to expand due to the catabolism of current or previous meals. Malpighian tubules swell as the gut contracts in size over time post-prandially. There is evidence that at a gross level the contents of the rectal vesicle are mechanically voided by the physical mechanism of overall gut expansion altering the effective idiosomal volume available during prey ingestion. A complete cycle of feeding, digestion, egestion and excretion is approximately 9 days. Hunger/starvation likely commences at 10 days after the start of feeding. Up to 15 days may be needed to completely clear the idiosoma of excretory material. Nomograms for predicting the likely feeding time of mites from observations of idiosomal guanine in field samples indicate that as few as 5-6 mites scoring positive for Malpighian tubule guanine out of 20 infers a high probability that the typical time from start of feeding in a population sample was about 6 days (range 3-8 days) ago.

Antibiotic prescribing patterns in the pediatric emergency department at Georgetown Public Hospital Corporation: a retrospective chart review.

BACKGROUND: The increase in antimicrobial-resistant infections has led to significant morbidity, mortality, and healthcare costs. The impact of antimicrobial resistance is greatest on low-income countries, which face the double burden of fewer antibiotic choices and higher rates of infectious diseases. Currently, Guyana has no national policy on rational prescribing. This study aims to characterize antibiotic prescribing patterns in children discharged from the emergency department at Georgetown Public Hospital Corporation (GPHC), as per the World Health Organization (WHO) prescribing indicators. METHODS: A retrospective chart review of pediatric patients (aged 1 month-13 years) seen in the GPHC emergency department between January and December 2012 was conducted. Outpatient prescriptions for eligible patients were reviewed. Patient demographics, diagnosis, and drugs prescribed were recorded. The following WHO Prescribing Indicators were calculated: i) average number of drugs prescribed per patient encounter, ii) percentage of encounters with an antibiotic prescribed, iii) percentage of antibiotics prescribed by generic name, and iv) percentage of antibiotics prescribed from essential drugs list or formulary. RESULTS: Eight hundred eleven patient encounters were included in the study. The mean patient age was 5.55 years (s = 3.98 years). 59.6 % (n = 483) patients were male. An average of 2.5 drugs were prescribed per encounter (WHO standard is 2.0). One or more antibiotic was prescribed during 36.9 % (n = 299) of all encounters (WHO standard is 30 %). 90.83 % of antibiotics were prescribed from the essential drugs formulary list and 30 % of the prescriptions included the drug's generic name. The average duration of antibiotic therapy was 5.73 days (s = 3.53 days). Of the 360 antibiotics prescribed, 74.7 % (n = 269) were broad-spectrum. B-lactam penicillins were prescribed most frequently (51.4 %), with amoxicillin being the most popular choice (33.9 %). The most common diagnoses were injuries (25.8 %), asthma (20 %), respiratory infections (19.5 %), and gastrointestinal infections (12.1 %). CONCLUSIONS: Per WHO prescribing indicators, the pediatric emergency department at GPHC has higher than standard rates of antibiotic use and polypharmacy. The department excels in adhering to the essential drug formulary. Our findings provide support for investigating drug utilization in other Guyanese settings, and to work towards developing a national rational prescribing strategy.

Effective health care for older people living and dying in care homes: a realist review.

BACKGROUND: Care home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes. METHODS: We conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group. RESULTS: Strategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change. CONCLUSION: How relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.

Impact of implementation of a novel antimicrobial stewardship tool on antibiotic use in nursing homes: a prospective cluster randomized control pilot study.

OBJECTIVES: To evaluate the impact of 'Resident Antimicrobial Management Plan' (RAMP), a novel antimicrobial stewardship tool on systemic antibiotic use for treatment of infection in nursing homes (NHs). METHODS: A pilot cluster randomized control study was conducted in 30 NHs in London. Pre-intervention, we collected point prevalence data on antimicrobial use on three occasions and total antimicrobial consumption for a 12 week period. Post-intervention data were collected in the same manner and included assessment of compliance with RAMP in the intervention group (IG). RESULTS: The number of residents included was 1628 pre-intervention [825 IG/803 control group (CG)] and 1610 post-intervention (838 IG/772 CG). The corresponding pre- and post-intervention point prevalence of systemic antibiotic prescribing for treatment of infection was 6.46% and 6.52% in the IG [estimated prevalence ratio: 1.01 (95% CI: 0.81-1.25), P = 0.94] compared with 5.27% and 5.83%, respectively, in the CG [estimated prevalence ratio: 1.11 (95% CI: 0.87-1.41), P = 0.4]. Total antibiotic consumption was 69.78 defined daily doses/1000 residents/day (DRD) pre-intervention and 66.53 DRD post-intervention in the IG compared with 49.68 and 51.92 DRD, respectively, in the CG. There was a significant decrease of 4.9% (3.25 DRD) in the IG (95% CI: 1.0%-8.6%) (P = 0.02) compared with a significant increase of 5.1% (2.24 DRD) in the CG (95% CI: 0.2%-10.2%) (P = 0.04). Main indications for antibiotics were lower respiratory tract infections (34.1%), urinary tract infections (28.5%) and skin/soft tissue infections (25.1%). CONCLUSIONS: This pilot study demonstrated that use of RAMP was associated with a statistically significant decrease in total antibiotic consumption and has the potential to be an important antimicrobial stewardship tool for NHs.

Gut expansion and contraction in the predatory soil mite Pergamasus longicornis (Mesostigmata: Parasitidae): a stiff system.

Mite digestive processes are inferred from gut expansion and contraction time in the free-living predatory soil mite Pergamasus longicornis (Berlese), estimated using a temporal series of histological sections. Gut regions (bar the rectal vesicle) behave broadly in unison for rapid initial filling (ingestion half-life about 2-3 min; max 8 min), but behave heterogeneously when slowly emptying (digestion/egestion half-life from about 2-3 h; max 8.5 h). Anterior gut regions fill and empty the earliest. Posterior gut regions take the longest to fill and to empty. Switching first from filling-predominating to emptying-predominating in the gut occurs around 2 h from the start of feeding. Median time for the initial completion of gut filling and for the commencement of gut emptying is 10 min and 12.5 h, respectively, from the start of feeding. Three phases of gut changes are critically discussed: rapid filling, concentration by fluid loss (via coxal glands), and slow emptying. Independent corroboration of coxal droplet formation is included. Predictions to confirm or refute postulated mechanisms of salivary, coxal or rectal water balance are given. Overall total gut filling (ingestion) plus gut emptying (digestion/egestion) time in this poikilotherm is approximately 29-52.5 h (1+ - 2+ days) at room temperature from the start of feeding on large dipteran prey ([Formula: see text] gut emptyings per day). Pergamasus longicornis exhibits the stiff digestive system of an intermittent 'bolus' feeder.

Estimation strategies for reacting to the identification of an association between the genome and adverse drug reactions.

The availability of high-resolution genetic profiling raises the possibility, during the course of a drug development program, of discovering a subset of patients at particular risk of an adverse drug reaction who might be excluded from subsequent randomization into studies and identified as unsuitable for post-licensing use. Such methods depend on the estimation of the risk of adverse drug reactions for patients with differing genetic profiles followed by an assessment of the risks and benefits of their exposure to the drug. In this paper we explore the performance of a number alternative statistical methods for the estimation of risk in terms of the success of the subsequent exclusion rules. The approaches were evaluated using a single-nucleotide polymorphism dataset concerning HIV patients at risk of hypersensitivity to the drug abacavir. Overall we found that a method based on LASSO performed better than the alternatives that we studied, which included a decision-theoretic Bayesian approach, and that its performance suggested suitability for its prospective implementation.

Comparison of staff and resident health status ratings in care homes.

BACKGROUND: Many care home residents cannot self-report their own health status. Previous studies have shown differences between staff and resident ratings. In 2012, we collected 10 168 pairs of health status ratings using the howRu health status measure. This paper examines differences between staff and resident ratings. METHOD: HowRu is a short generic person-reported outcome measure with four items: pain or discomfort (discomfort), feeling low or worried (distress), limited in what you can do (disability) and require help from others (dependence). A summary score (howRu score) is also calculated. Mean scores are shown on a 0-100 scale. High scores are better than low scores. Differences between resident and staff reports (bias) were analysed at the item and summary level by comparing distributions, analysing correlations and a modification of the Bland-Altman method. RESULTS AND CONCLUSIONS: Distributions are similar superficially but differ statistically. Spearman correlations are between 0.55 and 0.67. For items, more than 92.9% of paired responses are within one class; for the howRu summary score, 66% are within one class. Mean differences (resident score minus staff score) on 0-100 scale are pain and discomfort (-1.11), distress (0.67), discomfort (1.56), dependence (3.92) and howRu summary score (1.26). The variation is not the same for different severities. At higher levels of pain and discomfort, staff rated their discomfort and distress as better than residents. On the other hand, staff rated disability and dependence as worse than did residents. This probably reflects differences in perspectives. Red amber green (RAG) thresholds of 10 and 5 points are suggested for monitoring changes in care home mean scores.

Action following the discovery of a global association between the whole genome and adverse event risk in a clinical drug-development programme.

Observation of adverse drug reactions during drug development can cause closure of the whole programme. However, if association between the genotype and the risk of an adverse event is discovered, then it might suffice to exclude patients of certain genotypes from future recruitment. Various sequential and non-sequential procedures are available to identify an association between the whole genome, or at least a portion of it, and the incidence of adverse events. In this paper we start with a suspected association between the genotype and the risk of an adverse event and suppose that the genetic subgroups with elevated risk can be identified. Our focus is determination of whether the patients identified as being at risk should be excluded from further studies of the drug. We propose using a utility function to determine the appropriate action, taking into account the relative costs of suffering an adverse reaction and of failing to alleviate the patient's disease. Two illustrative examples are presented, one comparing patients who suffer from an adverse event with contemporary patients who do not, and the other making use of a reference control group. We also illustrate two classification methods, LASSO and CART, for identifying patients at risk, but we stress that any appropriate classification method could be used in conjunction with the proposed utility function. Our emphasis is on determining the action to take rather than on providing definitive evidence of an association.

Health status of care home residents: practicality and construct validity of data collection by staff at scale.

BACKGROUND: Medical diagnoses and assessed need for care are the prerequisites for planning and delivery of care to residents of care homes. Assessing the effectiveness of care is difficult. The aim of this study was to test the practicality and construct validity of the howRu health status measure using secondary analysis of a large data set. METHOD: The data came from a Bupa Care Homes Census in 2012, which covered 24 506 residents in 395 homes internationally (UK, Australia and New Zealand). Staff completed optical mark readable forms about each resident using a short generic health status measure, howRu. Response rates were used to assess practicality and expected relationships between health status and independent variables were used to assess the construct validity. RESULTS AND DISCUSSION: 19,438 forms were returned (79.3%) in 360 care homes (91.1%); complete health status data were recorded for 18 617 residents (95.8% of those returned). Missing values for any health status items mostly came from a small number of homes. The relationships between howRu and independent variables support construct validity. Factor analysis suggests three latent variables (discomfort, distress and disability/dependence). CONCLUSIONS: HowRu proved easy to use and practical at scale. The howRu health status measure shows good construct validity.

Development and initial testing of a Health Confidence Score (HCS).

Introduction: Patients need to feel confident about looking after their own health. This is needed to improve patient outcomes and clinical support. With few suitable tools available to measure self-care health confidence, we developed and validated a short, generic survey instrument for use in evaluation and quality improvement. Methods: The Health Confidence Score (HCS) was developed through literature review, patient and expert focus groups and discussions. This paper reports an initial survey (n = 1031, study 1) which identified some issues and a further face-to-face survey (n = 378, study 2) to test the construct and concurrent validity of the final version. Scores were correlated against the My Health Confidence (MHC) rating scale, howRu (health status measure) and relevant demographics. Results: The HCS is short (50 words) with good readability (reading age 8). It has four items covering health knowledge, capability to self-manage, access to help and shared decision-making; each has four response options (strongly agree, agree, neutral disagree). Items are reported independently and as a summary score.The mean summary score was 76.7 (SD 20.4) on 0-100 scale. Cronbach's alpha = 0.82. Exploratory factor analysis suggested that the four items relate to a single dimension. Correlation of the HCS summary score with MHC was high (Spearman r = 0.76). It was also associated with health status (Spearman r = 0.49), negatively with number of medications taken (r=-0.29) and age (r=-0.22) and not with ethnicity, having children or education level. Conclusions: The HCS is short, easy to use, with good psychometric properties and construct validity. Each item is meaningful independently and the summary score gives an overall picture of health confidence.