The development of a family-led novel intervention for delirium prevention and management in the adult intensive care unit: A co-design qualitative study.

AIM: The aim of this study was to codesign a Family Members' Voice Reorientation Intervention (FAMVR) for delirium prevention and management in critically ill adult patients through collaborative process with previous patients, families, and clinical staff. BACKGROUND: Delirium is a common consequence of intensive care admission, and there is limited evidence to support family-led interventions to prevent or minimise delirium in intensive care. People with lived experience of intensive care are seldom involved in codesigning delirium prevention and management interventions despite the identified benefits of their involvement in delirium care. DESIGN: Codesign qualitative study. METHODS: The process of co-designing was undertaken using the four stages of the Double Diamond model. Participants included people with lived experience of the intensive care unit, family members, and intensive care clinicians. The codesign approach was utilised, and data were gathered from a series of focus groups and individual interviews. Data were digitally recorded, transcribed verbatim, and analysed using thematic analysis. FINDINGS: Of the 26 people who indicated their interest in participating, 12 (46%) completed the first and second stages, and nine (35%) completed the third and fourth stages of the Family Members' Voice Reorientation Intervention development. All participant groups were represented in the fourth stage: patients (n = 4), family members (n = 1), nurses (n = 2), and medical staff (n = 2). Four themes were identified: message content, wording, reactions, and tone, all of which informed the prototype of the intervention and its associated domains. CONCLUSION: A codesign approach was important for developing a delirium management intervention. This process enabled participants to provide their feedback in the context of their unique experiences, which in turn enhanced the authenticity and appropriateness of this unique intervention.

Characterization of homologous sphingosine-1-phosphate lyase isoforms in the bacterial pathogen Burkholderia pseudomallei.

Sphingolipids (SLs) are ubiquitous elements in eukaryotic membranes and are also found in some bacterial and viral species. As well as playing an integral structural role, SLs also act as potent signaling molecules involved in numerous cellular pathways and have been linked to many human diseases. A central SL signaling molecule is sphingosine-1-phosphate (S1P), whose breakdown is catalyzed by S1P lyase (S1PL), a pyridoxal 5'-phosphate (PLP)-dependent enzyme that catalyzes the cleavage of S1P to (2E)-hexadecenal (2E-HEX) and phosphoethanolamine. Here, we show that the pathogenic bacterium, Burkholderia pseudomallei K96243, encodes two homologous proteins (S1PL2021 and S1PL2025) that display moderate sequence identity to known eukaryotic and prokaryotic S1PLs. Using an established MS-based methodology, we show that recombinant S1PL2021 is catalytically active. We also used recombinant human fatty aldehyde dehydrogenase to develop a spectrophotometric enzyme-coupled assay to detect 2E-HEX formation and measure the kinetic constants of the two B. pseudomallei S1PL isoforms. Furthermore, we determined the X-ray crystal structure of the PLP-bound form of S1PL2021 at 2.1 Å resolution revealing that the enzyme displays a conserved structural fold and active site architecture comparable with known S1PLs. The combined data suggest that B. pseudomallei has the potential to degrade host SLs in a S1PL-dependent manner.

Characterization of secreted sphingosine-1-phosphate lyases required for virulence and intracellular survival of Burkholderia pseudomallei.

Sphingosine-1-phosphate (S1P), a bioactive sphingolipid metabolite, plays a critical role in the orchestration of immune responses. S1P levels within the mammalian host are tightly regulated, in part through the activity of S1P lyase (S1PL) which catalyses its irreversible degradation. Herein, we describe the identification and characterization of secreted S1PL orthologues encoded by the facultative intracellular bacteria Burkholderia pseudomallei and Burkholderia thailandensis. These bacterial orthologues exhibited S1PL enzymatic activity, functionally complemented an S1PL-deficient yeast strain and conferred resistance to the antimicrobial sphingolipid D-erythro-sphingosine. We report that secretion of these bacterial S1PLs is pH-dependent, and is observed during intracellular infection. S1PL-deficient mutants displayed impaired intracellular replication in murine macrophages (associated with an inability to evade the maturing phagosome) and were significantly attenuated in murine and larval infection models. Furthermore, treatment of Burkholderia-infected macrophages with either S1P or a selective agonist of S1P receptor 1 enhanced bacterial colocalisation with LAMP-1 and reduced their intracellular survival. In summary, our studies confirm bacterial-encoded S1PL as a critical virulence determinant of B. pseudomallei and B. thailandensis, further highlighting the pivotal role of S1P in host-pathogen interactions. In addition, our data suggest that S1P pathway modulators have potential for the treatment of intracellular infection.

Reliability, feasibility, and validity of the quality of interactions schedule (QuIS) in acute hospital care: an observational study.

BACKGROUND: Research into relational care in hospitals will be facilitated by a focus on staff-patient interactions. The Quality of Interactions Schedule (QuIS) uses independent observers to measure the number of staff-patient interactions within a healthcare context, and to rate these interactions as 'positive social'; 'positive care'; 'neutral'; 'negative protective'; or 'negative restrictive'. QuIS was developed as a research instrument in long term care settings and has since been used for quality improvement in acute care. Prior to this study, its use had not been standardised, and reliability and validity in acute care had not been established. METHODS: In 2014 and 2015 a three - phase study was undertaken to develop and test protocols for the use of QuIS across three acute wards within one NHS trust in England. The phases were: (1) A pilot of 16 h observation which developed implementation strategies for QuIS in this context; (2) training two observers and undertaking 16 h of paired observation to inform the development of training protocols; (3) training four nurses and two lay volunteers according to a finalised protocol followed by 36 h of paired observations to test inter-rater agreement. Additionally, patients were asked to rate interactions and to complete a shortened version of the Patient Evaluation of Emotional Care during Hospitalisation (PEECH) questionnaire. RESULTS: Protocols were developed for the use of QuIS in acute care. Patients experienced an average of 6.7 interactions/patient/h (n = 447 interactions). There was close agreement between observers in relation to the number of interactions observed (Intraclass correlation coefficient (ICC) = 0.97) and moderate to substantial agreement on the quality of interactions (absolute agreement 73%, kappa 0.53 to 0.62 depending on weighting scheme). There was 79% agreement (weighted kappa 0.40: P < 0.001; indicating fair agreement) between patients and observers over whether interactions were positive, negative or neutral. CONCLUSIONS: Observers using clear QuIS protocols can achieve levels of agreement that are acceptable for the use of QuIS as a research instrument. There is fair agreement between observers and patients' rating of interactions. Further research is needed to explore the relationship between QuIS measures and reported patient experience.

Photosynthetic temperature responses of tree species in Rwanda: evidence of pronounced negative effects of high temperature in montane rainforest climax species.

The sensitivity of photosynthetic metabolism to temperature has been identified as a key uncertainty for projecting the magnitude of the terrestrial feedback on future climate change. While temperature responses of photosynthetic capacities have been comparatively well investigated in temperate species, the responses of tropical tree species remain unexplored. We compared the responses of seedlings of native cold-adapted tropical montane rainforest tree species with those of exotic warm-adapted plantation species, all growing in an intermediate temperature common garden in Rwanda. Leaf gas exchange responses to carbon dioxide (CO2 ) at different temperatures (20-40°C) were used to assess the temperature responses of biochemical photosynthetic capacities. Analyses revealed a lower optimum temperature for photosynthetic electron transport rates than for Rubisco carboxylation rates, along with lower electron transport optima in the native cold-adapted than in the exotic warm-adapted species. The photosynthetic optimum temperatures were generally exceeded by daytime peak leaf temperatures, in particular in the native montane rainforest climax species. This study thus provides evidence of pronounced negative effects of high temperature in tropical trees and indicates high susceptibility of montane rainforest climax species to future global warming.

Topical Adrenaline (1: 1000) for the Management of Severe Tarsal Conjunctival Chemosis.

Severe, refractory tarsal conjunctival chemosis developed in a severely autistic 9-year-old boy with a history of allergic conjunctival chemosis. The child was initially treated with topical and oral antihistamines, topical steroids, lubricants, and topical phenylephrine 10% with worsening of condition until complete eyelid eversion secondary to gross conjunctival chemosis with total obstruction of vision in the affected eye. Subsequently, he was successfully treated with topical adrenaline (1:1000) with rapid and lasting effect. The authors suggest that topical (1:1000) adrenaline is an effective therapy when other conservative therapies fail and can be useful in avoiding examination under general anesthetic and invasive intervention. Such a case has not been previously reported in the literature.

Thermal Profiles of Chainsaw Hollows and Natural Hollows during Extreme Heat Events.

Loss of hollow-bearing trees threatens many hollow-dependent wildlife. To mitigate this process, artificial chainsaw-carved hollows (CHs) are often created in dead trees, yet little is known about their thermal profiles. We measured temperatures inside 13 natural hollows (8 live and 5 dead trees) and 45 CHs (5 live and 40 dead trees) in the central west of NSW, Australia, over the course of 2 summers. Maximum temperatures and daily temperature ranges within natural hollows and artificial hollows were similar in 2017-2018. Hollow temperatures were lower in thicker-walled hollows than in thinner-walled hollows. During the January 2019 heatwave, temperatures inside CHs in dead trees exceeded 4-35 °C higher than the upper limit of the thermal neutral zone of sugar gliders-for 6.2 consecutive days (range 0-9 days). CHs in dead trees provided little buffering from thermal extremes; when air temperatures peaked at 44.6 °C, CHs in dead trees were on average 2.4 °C cooler than ambient (range: 5.5 °C cooler to 1.0 °C hotter than ambient). These results show that CHs created in dead trees may not provide suitable thermal conditions for hollow-dependent marsupials during summer heatwaves. Retention of large live trees, coupled with revegetation, is crucial for conserving hollow-dependent fauna in agricultural landscapes.

Enhancing resiliency and optimizing readiness in military personnel through psychological flexibility training: design and methodology of a randomized controlled trial.

Background: Enhancing resiliency and optimizing readiness in military personnel is a high priority for the U.S. Department of Defense. Most military resiliency-enhancement programs are evidence-informed interventions. However, few randomized studies have demonstrated efficacy of any intervention or training program to enhance resiliency and prevent the development of psychological health symptoms in military personnel when exposed to operational stressors. This manuscript provides an overview of the theoretical foundation, research design, and research methods of a preventive intervention trial designed to evaluate the efficacy of a training program to enhance resiliency and prevent psychological health symptoms in military personnel. The resiliency training intervention is based on Acceptance and Commitment Therapy (ACT), an evidence-based intervention with broad empirical support for improving functioning in those living with psychological and medical conditions. Method/design: This study will evaluate the efficacy of a two-day training program based on ACT for fostering psychological flexibility, the central target in ACT, for enhancing resiliency, and for preventing the development of psychological health symptoms. The research participants will be a non-clinical population of active duty military personnel (N = 600). The ACT-based training program (n = 300) will be compared to a military resiliency training as usual, known as Master Resilience Training (n = 300). Assessment measures will be administered at the baseline assessment, after training, prior to a military deployment, and after returning from a deployment. Qualitative interviews will be conducted to provide feedback on the training program.Clinical Trial Registration: NCT05094115.

Caruncular lesions: A 16-year single centre review in the United Kingdom.

BACKGROUND/AIMS: To review the clinicopathological features of caruncle biopsies carried out at a district general hospital in the United Kingdom (UK), and compare with other centres where data has been published. METHODS: Retrospective, single-centre, observational case series between 2004-2020. RESULTS: A total of 31 lesions from 31 patients were analysed. 18 of 31 patients were men (58%), and the age ranged from 12 to 91 years. 13 different histopathological types of lesions were identified in our case series, including 9 melanocytic nevi (29%), 7 benign squamous papillomas (23%), 5 skin adnexal lesions (16%), 3 chronic inflammation (10%), 3 epithelial cysts (10%), 1 basal cell carcinoma (3%), 2 malignant melanomas (6%) and l lymphoproliferative disorder (3%). Pre-operative suspected diagnoses were often vague but correct in 12 of 18 cases (67%), where data was available. CONCLUSION: The uncommon nature and variety of caruncular lesions make the diagnostic process difficult. Our case series is the first reported in the UK, showing a slightly higher proportion of malignant melanomas, in keeping with the population demographics. Excisional biopsies would, therefore, be prudent in the majority of cases to rule out any possible malignancy.

Frontal sinus infection leading to sino-orbital aspergillosis: a case report.

Sino-orbital aspergillosis is an uncommon but aggressive infection. It rarely originates from the frontal sinus due to the complex anatomy of the frontal recess and anteromedial position of its ostium. An 87-year-old man of Nigerian heritage with a history of multiple myeloma, chronic kidney disease and type 2 diabetes, presented to the eye clinic with a right tense swollen eyelid and proptosis. Computed tomography (CT) and magnetic resonance imaging (MRI) scan revealed a right superomedial mass communicating with the frontal sinus and biopsy confirmed an orbital aspergilloma. The patient was successfully treated with debulking surgery and anti-fungal treatment despite developing side effects to the drugs. To improve prognosis, ophthalmologists should be aware of this distinct entity and use a multi-disciplinary approach.

Effects of lighting illuminance levels on stair negotiation performance in individuals with visual impairment.

BACKGROUND: Stair-related falls of older people cause a substantial financial and social burden. Deterioration of the visual system amongst other factors put older people at a high risk of falling. Improved lighting is often recommended. The aim of this study was to investigate the effect of lighting illuminance on stair negotiation performance in older individuals with visual impairment. METHODS: Eleven participants aged 60 or over with a vision of 6/18 or worse ascended and descended a staircase under: 50 lx, 100 lx, 200 lx, 300 lx and distributed 200 lx lighting. A motion capture system was used to measure movements of the lower limb. Clearance, clearance variability, temporal and spatial parameters and joint/segment kinematics were computed. FINDINGS: There was no effect on clearance or clearance variability. Participants had lower speed, cadence, increased cycle time and stance time in the 50 lx compared to 300 lx and distributed 200 lx lighting in descent. The minimum hip angle in ascent was increased in the 200 lx lighting. Clearance was found to be moderately correlated with balance scores. INTERPRETATION: Individuals with visual impairment adopt precautionary gait in dim lighting conditions. This does not always result in improvements in the parameters associated with risk of falling (e.g. clearance).

Monitoring techniques of the western corn rootworm are the precursor to effective IPM strategies.

BACKGROUND: The western corn rootworm (WCR) is economically the most important pest of maize in Croatia. To predict WCR adult population abundance and variability, traditional, genetic and morphometric monitoring of populations was conducted over time through each phase of the WCR invasion process in Croatia. RESULTS: Through traditional monitoring it was shown that WCR established their current population and reached economic densities after 14 years persisting in the study area. Regression-tree-based modelling showed that the best predictor of WCR adult abundance was the total amount of rainfall. Genetic monitoring indicated that genetic differentiation increased over time at the intrapopulation level, and morphometric monitoring indicated that wing morphotypes varied according to edaphic landscape changes. CONCLUSION: Traditional population metric surveys are important in WCR integrated pest management (IPM), as such surveys can be effectively used to predict population abundances. Novel-use monitoring techniques such as genetics and geometric morphometrics can be used to provide valuable information on variation within and among populations. The monitoring techniques presented herein provide sound data to assist in the understanding of both WCR ecology and population genetics and may provide more information than that currently available using traditional techniques (e.g. sticky traps), and as such these additional techniques should be written into IPM for WCR.

Patients' perception of military doctors in fracture clinics--does the wearing of uniform make a difference?

We performed a study during our Trauma Week when patients who were referred from the accident department with fractures were reviewed in our fracture clinic. During our Trauma Week, Mister Thomas, Consultant Orthopaedic and Trauma Surgeon or Surgeon Lieutenant Commander McLean, Specialist Registrar in Orthopaedic and Trauma Surgery reviewed a total of 93 patients in fracture clinic. All patients were given an anonymous questionnaire regarding their perceptions of their attending clinician, 77 were completed. Forty-nine questionnaires regarding Surgeon Lieutenant Commander McLean and 28 regarding Mister Thomas were available for analysis. During the Trauma Week all patients were seen in the same location in identical cubicles by either of the two clinicians, consultations were typically brief lasting about five minutes. Throughout the week the clinicians, one military and one civilian, wore differing attire. The military uniform comprised Royal Navy number four action working dress. The civilian attire comprised 'dog-robbers' (jacket, shirt with tie and smart trousers). The hypothesis tested was that the use of military uniform might alter patients' perceptions of their attending clinician. Our results appear to demonstrate that the attire of the attending clinician does not adversely influence patients' perceptions of their attending clinician.

The Yellow Brick Road: a values based curriculum model.

Within the United Kingdom, the Nursing and Midwifery Council (NMC) requires that nurses and midwives are of 'good character' at the point of registration. This paper sets out how good character has been conceptualised within one U.K. higher education institution and presents a model of "values based enquiry" which aims to develop the 'character' of students. The paper presents three qualities ("the heart", "the nerve" and "the brain") which represent 'good character' and which are believed to underpin values based Nursing or Midwifery practice. The development of these qualities is argued to be reliant upon helping students to develop intrinsic professional values of care and compassion. The role of these character qualities in nursing practice and education is outlined, as are the ways in which they have led to the development of a model for values based enquiry. This model represents a vision of the nature of professional education which may be shared by staff and students, whilst offering a model for learning and teaching based upon recognised educational principles. An argument is advanced that the adoption of a values based enquiry model may develop and nurture the habits of mind which are necessary for the development of 'good character'.

Femoroacetabular impingement: a review of diagnosis and management.

Hip pain in adults has traditionally been associated with osteoarthritis in the joint. However, many young patients with hip pain do get referred to orthopaedic surgeons without arthritis. Subtle bony and soft tissues abnormalities can present with hip pain in the active young adult. These abnormalities can lead to premature arthritis. With the improvements in clinical examination for hip impingement, radiological imaging using magnetic resonance arthrography (MRA) and or computed tomograms (CT) Scans, these lesions are being detected early. Though the cause of primary osteoarthritis is unknown, it is suggested that femoro-acetabular impingement (FAI) may be responsible for the progression of the disease in these patients. FAI is a pathological condition leading to abutment between the proximal femur and the acetabular rim. Two different mechanisms are described, although a combination of both is seen in clinical practice. Cam impingement is a result of reduced anterior femoral head neck offset. Pincer lesion is caused by abnormalities on the acetabular side. FAI due to either mechanism can lead to chondral lesions and labral pathology. Patients present with groin pain and investigated with radiographs, CT and MRA. Surgery is the treatment of choice. Open or arthroscopic exploration of the hip is undertaken with bony resection to improve the femoral head neck junction with resection or repair of the damaged labrum. This may involve femoral osteochondroplasty for the cam lesion and acetabular rim resection for pincer lesion. There is no difference in outcome between open and arthroscopic surgery for FAI.

Chronic exertional compartment syndrome with medial tibial stress syndrome in twins.

Chronic exertional compartment syndrome and medial tibial stress syndrome are uncommon conditions that affect long-distance runners or players involved in team sports that require extensive running. We report 2 cases of bilateral chronic exertional compartment syndrome, with medial tibial stress syndrome in identical twins diagnosed with the use of a Kodiag monitor (B. Braun Medical, Sheffield, United Kingdom) fulfilling the modified diagnostic criteria for chronic exertional compartment syndrome as described by Pedowitz et al, which includes: (1) pre-exercise compartment pressure level >15 mm Hg; (2) 1 minute post-exercise pressure >30 mm Hg; and (3) 5 minutes post-exercise pressure >20 mm Hg in the presence of clinical features. Both patients were treated with bilateral anterior fasciotomies through minimal incision and deep posterior fasciotomies with tibial periosteal stripping performed through longer anteromedial incisions under direct vision followed by intensive physiotherapy resulting in complete symptomatic recovery. The etiology of chronic exertional compartment syndrome is not fully understood, but it is postulated abnormal increases in intramuscular pressure during exercise impair local perfusion, causing ischemic muscle pain. No familial predisposition has been reported to date. However, some authors have found that no significant difference exists in the relative perfusion, in patients, diagnosed with chronic exertional compartment syndrome. Magnetic resonance images of affected compartments have indicated that the pain is not due to ischemia, but rather from a disproportionate oxygen supply versus demand. We believe this is the first report of chronic exertional compartment syndrome with medial tibial stress syndrome in twins, raising the question of whether there is a genetic predisposition to the causation of these conditions.

The efficacy of multimodal high-volume wound infiltration in primary total hip replacement.

Multimodal wound infiltration with local anesthetics, adrenaline, and nonsteroidal anti-inflammatory agents can lower the opiate intake, reduce the length of stay, and enhance early mobilization after total hip arthroplasty (THA). A retrospective review of 204 patients undergoing primary THA was undertaken. One hundred two patients had their wounds infiltrated with ropivacaine, adrenaline, and ketorolac by the operating surgeon intraoperatively. Subsequently, a 19-gauge wound catheter was inserted percutaneously into the hip joint. Patients received 2 further top-up doses of 20 mL of ropivacaine (7.5 mg/mL) at 10 and 20 hours postoperatively. These patients were compared to a control group of 102 patients who received no local infiltration. Both groups were comparable in terms of body mass index and age. Opiate consumption in the first 48 hours after surgery and length of hospital stay were recorded. The mean consumption of morphine in the treatment group was 42.3 mg (standard deviation [SD], 31.2 mg) compared to 60.9 mg (SD, 33.8 mg) in the control group (P<.0001). The mean length of stay was significantly reduced from 5.2 days (SD, 1.6 days) in the control group to 4 days (SD, 1.3 days) in the treatment group (P<.0001). The time needed by the patients to walk for 3 meters after surgery was significantly reduced in the treatment group (median, 25 vs 46.1 hours; interquartile range, 20.7- 45.1 vs 27.2- 50.9; P<.0001). This is the largest series to demonstrate that a multimodal perioperative wound infiltration technique in primary THA surgery leads to early attainment of immediate postoperative rehabilitation milestones and reduced length of stay along with reduction in postoperative opiate consumption.

Mammalian hair as an accumulative bioindicator of metal bioavailability in Australian terrestrial environments.

The current study represents the first investigation of the suitability of marsupial and eutherian mammalian hair as indicator tissue for metal exposure and accumulation within contaminated Australian terrestrial ecosystems. A soil metal contamination gradient was established across 22 sites at increasing distances from a decommissioned Lead/Zinc smelter in NSW, Australia. Within each site, soil and small mammal populations were sampled. An Australian native marsupial, the insectivorous Brown Antechinus, Antechinus stuartii: Dasyuridae, and introduced rodents, the omnivorous Brown or Norway Rat, Rattus norvegicus: Muridae and the Black Rat, Rattus rattus: Muridae were assessed for hair concentrations of Cadmium (Cd), Copper (Cu), Lead (Pb) and Zinc (Zn). Metals in soil were most elevated at sites within close proximity to the smelter, with soil metal concentrations decreasing with distance from the smelter. The non-essential metals Pb and Cd were accumulated in hair, both metals exhibiting positive linear relationships with environmental exposure (soil metal concentrations). When the variables of weight and snout-vent length were considered, no further contribution in terms of explaining the variability in hair Cd or Pb was observed for all species examined. The essential metals Cu and Zn were regulated in hair, remaining similar across the metal contamination gradient. A significant negative correlation between snout-vent length and hair Cu concentration was found for the Brown Rat; greater hair Cu concentrations were found in smaller individuals of this species. Accumulation of Pb to hair was similar among species while concentrations of Cd in Brown Rat hair were higher than both Black Rat and Brown Antechinus hair. As each of the three aforementioned species exhibit similar bioaccumulation relationships for Pb, we suggest that sampling hair from introduced rodents (pest species) may provide a suitable proxy for the assessment of Pb bioavailability for a range of small mammals within Australian urban remnants.