Altered network stability in progressive supranuclear palsy.

The clinical syndromes of Progressive Supranuclear Palsy (PSP) may be mediated by abnormal temporal dynamics of brain networks, due to the impact of atrophy, synapse loss and neurotransmitter deficits. We tested the hypothesis that alterations in signal complexity in neural networks influence short-latency state transitions. Ninety-four participants with PSP and 64 healthy controls were recruited from two independent cohorts. All participants underwent clinical and neuropsychological testing and resting-state functional MRI. Network dynamics were assessed using hidden Markov models and neural signal complexity measured in terms of multiscale entropy. In both cohorts, PSP increased the proportion of time in networks associated with higher cognitive functions. This effect correlated with clinical severity as measured by the PSP-rating-scale, and with reduced neural signal complexity. Regional atrophy influenced abnormal brain-state occupancy, but abnormal network topology and dynamics were not restricted to areas of atrophy. Our findings show that the pathology of PSP causes clinically relevant changes in neural temporal dynamics, leading to a greater proportion of time in inefficient brain-states.

Guidelines for the management of diabetes in care homes during the Covid-19 pandemic.

The National Diabetes Stakeholders Covid-19 Response Group was formed in early April 2020 as a rapid action by the Joint British Diabetes Societies for Inpatient Care, Diabetes UK, the Association of British Clinical Diabetologists, and Diabetes Frail to address and support the special needs of residents with diabetes in UK care homes during Covid-19. It was obvious that the care home sector was becoming a second wave of Covid-19 infection and that those with diabetes residing in care homes were at increased risk not only of susceptibility to infection but also to poorer outcomes. Its key purposes included minimising the morbidity and mortality associated with Covid-19 and assisting care staff to identify those residents with diabetes at highest risk of Covid-19 infection. The guidance was particularly created for care home managers, other care home staff, and specialist and non-specialist community nursing teams. The guidance covers the management of hyperglycaemia by discussion of various clinical scenarios that could arise, the management of hypoglycaemia, foot care and end of life care. In addition, it outlines the conditions where hospital admission is required. The guidance should be regarded as interim and will be updated as further medical and scientific evidence becomes available.

Guidelines for the management of diabetes services and patients during the COVID-19 pandemic.

The UK National Diabetes Inpatient COVID Response Group was formed at the end of March 2020 to support the provision of diabetes inpatient care during the COVID pandemic. It was formed in response to two emerging needs. First to ensure that basic diabetes services are secured and maintained at a time when there was a call for re-deployment to support the need for general medical expertise across secondary care services. The second was to provide simple safe diabetes guidelines for use by specialists and non-specialists treating inpatients with or suspected of COVID-19 infection. To date the group, comprising UK-based specialists in diabetes, pharmacy and psychology, have produced two sets of guidelines which will be continually revised as new evidence emerges. It is supported by Diabetes UK, the Association of British Clinical Diabetologists and NHS England.

The design and evaluation of a novel low-cost portable ventilator.

Modern mechanical ventilator technologies broadly consist of digitally-controlled electronic devices and analogue systems driven by compressed gas sources. Drawbacks such as high cost, complex maintenance and the need for cumbersome sources of compressed driving gas hinder adoption in pre-hospital and low-resource environments. We describe the evaluation and testing of a simple, low-cost alternative ventilator that uses a novel pressure-sensing approach and control algorithm. This is designed to provide portable positive-pressure mechanical ventilation at a reduced cost, while autonomously monitoring patient condition and important safety parameters. A prototype ventilator was constructed and evaluated using an anaesthetic test-lung as a patient surrogate. Using a modifiable test-lung and digital pressure sensor, we investigated ventilation pressure waveform circuit leak detection, and compliance and resistance change detection. During intermittent positive-pressure ventilation to the test-lung, the prototype system showed acceptable pressure waveform parameters: all simulated circuit leaks ≥ 6 mm2 in size were detected; compliance changes were detected between 10 ml.cmH2 O-1 , 20 ml.cmH2 O-1 and 50 ml.cmH2 O-1 ; and resistance changes were detected across the available simulated range. These results show this prototype technology has the potential to provide safe emergency ventilation without the use of any complex digital sensors or software while its construction and design enables significant reductions in cost and complexity. The study suggests further work is now justified in progressing the technology to clinical trials.

Automated Assessment of Movement Impairment in Huntington's Disease.

Quantitative assessment of movement impairment in Huntington's disease (HD) is essential to monitoring of disease progression. This paper aimed to develop and validate a novel low cost, objective automated system for the evaluation of upper limb movement impairment in HD in order to eliminate the inconsistency of the assessor and offer a more sensitive, continuous assessment scale. Patients with genetically confirmed HD and healthy controls were recruited to this observational study. Demographic data, including age (years), gender, and unified HD rating scale total motor score (UHDRS-TMS), were recorded. For the purposes of this paper, a modified upper limb motor impairment score (mULMS) was generated from the UHDRS-TMS. All participants completed a brief, standardized clinical assessment of upper limb dexterity while wearing a tri-axial accelerometer on each wrist and on the sternum. The captured acceleration data were used to develop an automatic classification system for discriminating between healthy and HD participants and to automatically generate a continuous movement impairment score (MIS) that reflected the degree of the movement impairment. Data from 48 healthy and 44 HD participants was used to validate the developed system, which achieved 98.78% accuracy in discriminating between healthy and HD participants. The Pearson correlation coefficient between the automatic MIS and the clinician rated mULMS was 0.77 with a p-value < 0.01. The approach presented in this paper demonstrates the possibility of an automated objective, consistent, and sensitive assessment of the HD movement impairment.

Similarities and Differences Between Physician Assistant Program and Medical School Mission Statement Themes.

PURPOSE: The purpose of this study was to examine the concordance of US physician assistant (PA) program mission statements with those of US public- and private-sponsored medical schools. With the exception of a broader medical school focus on research, the authors hypothesized that little difference in mission statement congruence would be found in a comparison of medical schools and PA programs. METHODS: Mission statements of 209 of the 210 accredited US PA programs as of May 2016 were obtained and analyzed. Keywords and phrases were identified, coded, and analyzed using NVivo. Themes that previously reported medical school mission statement analyses (including education, research, service, primary care, diversity, prevention, provider distribution, and cost control) were examined. Additional themes of evidence-based medicine (EBM), interprofessional care, patient safety, and quality improvement were included in the analyses. RESULTS: Analyses revealed similar emphasis in both PA programs and medical schools on themes of education, prevention, and cost control, with dissimilar emphases on themes of research, service, primary care, diversity, and provider distribution. Physician assistant programs were more likely to emphasize interprofessional care than EBM, patient safety, or quality improvement. CONCLUSIONS: In the comparison of mission statements of medical schools and PA programs, much less congruence was found than had been hypothesized. Although this study examined the similarities and differences between the mission statements of US medical schools and PA programs, it did not examine the extent to which programs succeeded in meeting the stated missions. Additional research is necessary to understand the factors that determine whether mission statements are actualized in measurable deliverables.

Consumer segmentation and time interval between types of hospital admission: a clinical linkage database study.

Background: Healthcare policies target unplanned hospital admissions and 30-day re-admission as key measures of efficiency, but do not focus on factors that influence trajectories of different types of admissions in the same patient over time. Objectives: To investigate the influence of consumer segmentation and patient factors on the time intervals between different types of hospital admission. Research design, subjects and measures: A cohort design was applied to an anonymised linkage database for adults aged 40 years and over (N = 58 857). Measures included Mosaic segmentation, multimorbidity defined on six chronic condition registers and hospital admissions over a 27-month time period. Results: The shortest mean time intervals between two consecutive planned admissions were: 90 years and over (160 days (95% confidence interval (CI): 146-175)), Mosaic groups 'Twilight subsistence' (171 days (164-179)) or 'Welfare borderline' and 'Municipal dependency' (177 days (172-182)) compared to the reference Mosaic groups (186 days (180-193)), and multimorbidity count of four or more (137 days (130-145)). Mosaic group 'Twilight subsistence' (rate ratio (RR) 1.22 (95% CI: 1.08-1.36)) or 'Welfare borderline' and 'Municipal dependency' RR 1.20 (1.10-1.31) were significantly associated with higher rate to an unplanned admission following a planned event. However, associations between patient factors and unplanned admissions were diminished by adjustment for planned admissions. Conclusion: Specific consumer segmentation and patient factors were associated with shorter time intervals between different types of admissions. The findings support innovation in public health approaches to prevent by a focus on long-term trajectories of hospital admissions, which include planned activity.

Measuring respiratory symptoms in clinical trials of COPD: reliability and validity of a daily diary.

BACKGROUND: Although respiratory symptoms are characteristic features of COPD, there is no standardised method for quantifying their severity in stable disease. OBJECTIVE: To evaluate the EXACT-Respiratory Symptom (E-RS) measure, a daily diary comprising 11 of the 14 items in the Exacerbations of Chronic Pulmonary Disease Tool (EXACT). METHODS: Qualitative: patient focus group and interviews to address content validity. Quantitative: secondary data analyses to test reliability and validity. RESULTS: Qualitative: n=84; mean (SD) age 65 (10) years, FEV1 1.2(0.4) L; 44% male. Subject descriptions of their respiratory symptoms were consistent with E-RS content and structure. Quantitative: n=188; mean (SD) age 66 (10) years, FEV1 1.2(0.5) L; 50% male. Factor analysis (FA) showed 3 subscales: RS-Breathlessness, RS-Cough & Sputum, and RS-Chest Symptoms; second-order FA supported a general factor and total score. Reliability (total and subscales): 0.88, 0.86, 0.73, 0.81; 2-day test-retest ICC: 0.90, 0.86, 0.87, 0.82, respectively. VALIDITY: Total scores correlated significantly (p < 0.0001) with SGRQ Total (r=0.75), Symptoms (r=0.66), Activity (r=0.57), Impact (r=0.70) scores; subscale correlations were also significant (r=0.26, p < 0.05 (RS-Chest Symptoms with Activity) to r=0.69, p < 0.0001 (RS-Cough & Sputum with Symptoms). RS-Breathlessness correlated with rescue medication use (r=0.32, p < 0.0001), clinician-reported mMRC (r=0.33, p < 0.0001), and FEV1% predicted (r=-0.17, p < 0.05). E-RS scores differentiated groups based on chronic bronchitis diagnosis (p < 0.01-0.001), smoking status (p < 0.05-0.001), and rescue medication use (p < 0.05-0.0001). CONCLUSIONS: Results suggest the RS-Total is a reliable and valid instrument for evaluating respiratory symptom severity in stable COPD. Further study of sensitivity to change is warranted.

Parity of esteem begins at home: translating empirical psychiatric research into effective public mental health.

There is increasing recognition that parity of esteem between mental and physical health disorders is essential to improve the course, outcome and quality of life of individuals within different populations. Achieving this parity now underpins the objectives of several nations. Here, we argue that parity of esteem between mental and physical health can only be realized when parity of esteem also exists across mental health disorders, particularly in terms of service commissioning and planning. Using first-episode psychosis and early intervention in psychosis services as a motivating example, we demonstrate how carefully conducted psychiatric epidemiology can be translated to develop precise forecasts of the anticipated incidence of first-episode psychosis in different populations, based on an understanding of underlying local needs and inequalities. Open-access prediction tools such as PsyMaptic will allow commissioners of mental health services to more effectively allocate resources across services, based on empirical evidence and local need, thus reducing inequalities in access to mental health care.

The Texas health workforce benefit of military physician assistant program veterans.

PURPOSE: Little is known about the benefits to society of the educational development of health personnel in the military who return to civilian life and continue their careers. The U.S. Department of Defense has produced physician assistants (PAs) since the early 1970s, and PA training is now consolidated into one location in Texas as the Interservice Physician Assistant Program (IPAP). We studied redistribution of PAs upon service departure to determine if IPAP attendance had an effect on the Texas PA workforce. METHODS: The Texas Medical Board dataset of licensed PAs was examined to identify program attended, practice specialty by supervising physician designation, practice location, and primary care or specialty care practice designation. Primary care was defined as family medicine, general pediatrics, or general internal medicine. All other designations were classified as specialty practice. RESULTS: Of 6016 licensed Texas PAs, 425 (7.0%) reported attending a military PA training program. Of the 254 PAs in full-time civilian clinical practice, 148 (58.3%) reported practice in primary care settings, and 106 (41.7%) reported specialty clinical practice settings. DISCUSSION: With the average military officer retirement age of 47 years and the 2010 average U.S. retirement age of 64 years for men and 62 for women, an estimated 16 years of community workforce productivity is provided per veteran PA following completion of military service. We estimated over 47,000 outpatient visits are provided per PA following military service. The care provided can be measured as a positive return-on-investment of taxpayer-provided education.

The use of U-500 regular insulin in the management of patients with obesity and insulin resistance.

The rise in prevalence of obesity and diabetes has created a challenge in managing increasing numbers of patients who require high doses of insulin. This article reviews the published literature on the properties of U-500 insulin and its use in clinical practice. U-500 insulin is likely to have a longer time to peak effect and a longer duration of action than similar doses of U-100 insulin. Evidence for its use in clinical practice rests on retrospective case series, which suggests that the use of U-500 insulin either by multiple daily injections or a continuous subcutaneous insulin infusion is effective in improving glycaemic control. To prevent insulin dosing and administration errors, great care must be taken in providing staff and patient education, and in developing policies for the management of patients on U-500 insulin who are admitted to hospital.

Nutrition economics - food as an ally of public health.

Non-communicable diseases (NCD) are a major and increasing contributor to morbidity and mortality in developed and developing countries. Much of the chronic disease burden is preventable through modification of lifestyle behaviours, and increased attention is being focused on identifying and implementing effective preventative health strategies. Nutrition has been identified as a major modifiable determinant of NCD. The recent merging of health economics and nutritional sciences to form the nascent discipline of nutrition economics aims to assess the impact of diet on health and disease prevention, and to evaluate options for changing dietary choices, while incorporating an understanding of the immediate impacts and downstream consequences. In short, nutrition economics allows for generation of policy-relevant evidence, and as such the discipline is a crucial partner in achieving better population nutritional status and improvements in public health and wellness. The objective of the present paper is to summarise presentations made at a satellite symposium held during the 11th European Nutrition Conference, 28 October 2011, where the role of nutrition and its potential to reduce the public health burden through alleviating undernutrition and nutrition deficiencies, promoting better-quality diets and incorporating a role for functional foods were discussed.

Usefulness of EQ-5D for evaluation of health-related quality of life in young adults with first-episode psychosis.

PURPOSE: To evaluate the psychometric properties of the EQ-5D and the usefulness of this instrument in psychiatric practice as a measure of health-related quality of life (HRQoL) in a sample of young adults with first-episode psychosis. METHODS: The validity of individual questionnaire items is studied using an Item Response/Latent Trait Theory modeling approach. Sensitivity of response patterns on EQ-5D items to particular diagnostic subtypes of psychosis is investigated using a finite mixture modeling approach through latent class analysis. Finally, a structural equation modeling framework is used to study differential item functioning via a multigroup approach. RESULTS: Results suggest that the data closely correspond to the Rasch Rating Scale Model, and therefore that EQ-5D latent scores are equal interval measures. Despite comprising relatively few items, the instrument yields reliable measures of HRQoL for group comparisons and cost-effectiveness evaluation, but EQ-5D score is too imprecise for the assessment of HRQoL for clinical purposes at the individual level. A significant relationship was found between EQ-5D responses and type of psychosis due to inclusion of item anxiety/depression in EQ-5D. Two items (anxiety/depression, functioning in usual activities) showed an ethnicity bias. CONCLUSIONS: Psychometric evidence confirmed the EQ-5D to be a valid, interval measure that is scalable according to Rasch principles.

Institutional sponsorship, student debt, and specialty choice in physician assistant education.

Physician assistant (PA) educational programs emerged in the mid 1960s in response to health workforce shortages and decreasing access to care and, specifically, the decline of generalist physicians. There is wide diversity in the institutional sponsorship of PA programs, and sponsorship has trended of late to private institutions. We analyzed trends in sponsorship of PA educational programs and found that, in the past 15 years, there were 25 publicly sponsored and 96 privately sponsored programs that gained accreditation, a 3.84:1 private-to-public ratio. Of the 96 privately sponsored programs, only seven (7.3%) were located within institutions reporting membership in the Association of Academic Health Centers, compared to eight of the 25 publicly sponsored programs (32%). In 1978, a large majority (estimated 43 of the 48 then-existing PA programs) received their start-up or continuing funding through the US Public Health Service, Section 747 Title VII program, whereas in 2012 there were far fewer (39 of 173). The finding of a preponderance of private institutions may correlate with the trend of PAs selecting specialty practice (65%) over primary care. Specialty choice of graduating PA students may or may not be related to the disproportionate debt burden associated with attending privately sponsored programs, where the public-to-private tuition difference is significant. Moreover, the waning number of programs participating in the Title VII grant process may also have contributed to the overall rise in tuition rates among PA educational programs due to the loss of supplemental funding.

Workshop Report: concepts and methods in the economics of nutrition--gateways to better economic evaluation of nutrition interventions.

Improving health through better nutrition of the population may contribute to enhanced efficiency and sustainability of healthcare systems. A recent expert meeting investigated in detail a number of methodological aspects related to the discipline of nutrition economics. The role of nutrition in health maintenance and in the prevention of non-communicable diseases is now generally recognised. However, the main scope of those seeking to contain healthcare expenditures tends to focus on the management of existing chronic diseases. Identifying additional relevant dimensions to measure and the context of use will become increasingly important in selecting and developing outcome measurements for nutrition interventions. The translation of nutrition-related research data into public health guidance raises the challenging issue of carrying out more pragmatic trials in many areas where these would generate the most useful evidence for health policy decision-making. Nutrition exemplifies all the types of interventions and policy which need evaluating across the health field. There is a need to start actively engaging key stakeholders in order to collect data and to widen health technology assessment approaches for achieving a policy shift from evidence-based medicine to evidence-based decision-making in the field of nutrition.

The conduct of dental research: the protocol, a guide.

BACKGROUND: Research today requires detailed planning to ensure efficient work, to raise funding and to fit into time constraints. AIM: The aim of this article is to provide a broad guidance on the layout and content of a research protocol. METHOD: Years of experience in writing research protocols were used to give guidance on writing, timings, content, layout and successful completion.

Schizophrenia trial participation: perceived inclusion barriers and beliefs about antipsychotics.

BACKGROUND: Patient recruitment is the universal rate-limiting factor for randomized controlled trials (RCTs) in all medical specialties. This study examined the opinions on perceived inclusion barriers and beliefs about antipsychotics of a group of psychiatrists participating in a pragmatic RCT on antipsychotic drugs in schizophrenia (the GiSAS trial). METHODS: A survey of all clinicians working in the trial recruiting centers was performed exploring factors associated to the respondents' opinions. RESULTS: Of 465 clinicians, 278 (59.8%) responded to the questionnaire. Respondents (n=278) were mainly influenced by clinical and trial-related barriers (89%). Factors such as work setting and antipsychotic prescription choices appeared to be related to perceived inclusion barriers. Most respondents believed in the superiority of SGAs (62.9%), one-third indicating drug company representatives as the most important source of information; this was related to further optimism towards SGAs. CONCLUSIONS: Respondents were affected mainly by system-related barriers, whereas personal barriers were given less weight. The influence of industry-mediated information could have affected opinions on SGAs and the lack of uncertainty about antipsychotics attitudes towards trial participation.

Properties of the COPD assessment test in a cross-sectional European study.

A short, easy-to-use health status questionnaire is needed in the multidimensional assessment of chronic obstructive pulmonary disease (COPD) in routine practice. The performance of the eight-item COPD assessment test (CAT) was analysed in 1,817 patients from primary care in seven European countries. The CAT has a scoring range of 0-40 (high score representing poor health status). Mean CAT scores indicated significant health status impairment that was related to severity of airway obstruction, but within each Global Initiative for Obstructive Lung Disease stage (I to IV) there was a wide range of scores (I: 16.2 ± 8.8; II: 16.3 ± 7.9; III: 19.3 ± 8.2; and IV: 22.3 ± 8.7; I versus II, p = 0.88; II versus III, p<0.0001; III versus IV, p = 0.0001). CAT scores showed relatively little variability across countries (within ± 12% of the mean across all countries). Scores were significantly better in patients who were stable (17.2 ± 8.3) versus those suffering an exacerbation (21.3 ± 8.4) (p<0.0001); and in patients with no (17.3 ± 8.1) or one or two (16.6 ± 8.2) versus three or more (19.7 ± 8.5) comorbidities (p<0.0001 for both). The CAT distinguished between classes of other impairment measures and was strongly correlated with the St George's Respiratory Questionnaire (r = 0.8, p<0.0001). The CAT is a simple and easy-to-use questionnaire that distinguishes between patients of different degrees of COPD severity and appears to behave the same way across countries.

A quantitative assessment of residual protein levels on dental instruments reprocessed by manual, ultrasonic and automated cleaning methods.

OBJECTIVE: To assess residual protein on dental instruments cleaned in general dental practice by manual, manual plus ultrasonic and automated washer disinfector (AWD) processes. DESIGN AND SETTING: Instruments submitted by 30 dental surgeries in the South West of England. SUBJECTS (MATERIALS) AND METHODS: Instruments analysed were matrix bands, associated retaining clips, diamond and stainless steel burs, extraction forceps and hand scalers. Each instrument was visually assessed under magnification for residual debris. Residual protein was extracted by immersion in detergent and sonication. A collection of used but uncleaned instruments of each type (n = 177) was also analysed for adherent protein using ophthalaldehyde/N-acetylcysteine reagent. MAIN OUTCOME MEASURES: Residual protein levels allowed comparisons to be made on the effectiveness of different cleaning processes. RESULTS: One thousand, three hundred and four instruments were analysed. Observational data demonstrated several shortcomings in cleaning chemistries and operation of the AWD. For uncleaned instruments, median residual protein levels ranged from 0.4 µg (stainless steel burs) to 462 µg (extraction forceps). Following manual washing, median protein levels ranged from 0.3-78 µg; for manual plus ultrasonic washing, levels ranged from 9-39 µg and AWD levels ranged from 0.3-27 µg. Manual washing combined with ultrasonic cleaning was significantly less effective than the other two processes (p <0.008). AWDs reduced the variability in the cleaning process. No correlation was found between visual scoring and residual protein determination. CONCLUSION(S): There was a wide variation in residual protein levels both within and between different methods and instruments and this underlines the complexity of this process.