What are the goals of care for older people living with frailty when they access urgent care? Are those goals attained? A qualitative view of patient and carer perspectives.

STUDY OBJECTIVE: Little is known of the goals of care of older people living with frailty when they access urgent care. Equally whether these goals are attained from a patient and carer perspective is often unclear. This qualitative study examined the views of older people living with frailty and their families in relation to specific episodes of urgent care, what they wanted to achieve and whether those goals were attained. METHODS: Semi-structured interviews with older people living with frailty and their families between Jan and July 2019. Patient and carer participants were recruited in three hospitals in England and interviewed following the urgent care episode. Interviews were audio-recorded, transcribed verbatim and analysed following the principles of the Framework approach. Results were validated by an older people's involvement group. RESULTS: Forty participants were interviewed either alone or jointly (24 patients and 16 carers), describing episodes of urgent care which started in ED for 28 patients. The goals of care for participants accessing emergency care were that their medical problem be diagnosed and resolved; information about tests and treatment be given to them and their relatives; they receive an appropriate well-planned discharge to their own home with support where needed and without readmission or re-attendance at ED; and that they retain mobility, function and normal activities. Participants perceived that many of these goals of care were not attained. CONCLUSIONS: Older people living with frailty have heterogeneous urgent care goals which require individual ascertainment. Identifying these goals of care early could result in improved attainment through person-centred care.

A longitudinal assessment of occupational stress in Emergency Department Nursing Staff.

AIMS: To examine perceptions of occupational stress in Emergency Department (ED) nurses and measure the impact of interventions to address them. BACKGROUND: Cross-sectional studies internationally have established that Emergency Department (ED) nursing staff experience high levels of occupational stress. Few however have examined changes in perceptions of stress over time or the impact of interventions to address them. EVALUATION: A structured questionnaire completed by volunteer nursing staff in one United Kingdom ED assessing perceptions of occupational stress and job satisfaction. Questionnaire rounds were administered in 2014 (T1), 2015 (T2) and 2017 (T3) at 18-month intervals. Statistical analyses were conducted using multivariate regression, t-tests and Mann-Whitney U tests. KEY ISSUE: Statistically significant improvements in effort-reward balance, relational justice and job satisfaction were seen between T2 and T3 for nurses completing questionnaires at all three time points, but not for other stressors. CONCLUSION: This study suggests that organisational interventions, supported by robust research data and consistent departmental leadership can positively influence perceptions of organisational stress in ED nurses. Our approach is generic, internationally applicable and can be adopted in all EDs. IMPLICATIONS OF NURSING MANAGEMENT: These occupational stressors are common to all EDs. Nurse managers should know their distribution amongst their staff. Such data can inform interventions to achieve maximal benefits for staff wellbeing and may be of value when targeting resources in times of financial pressure.

Obesity and neurological disorders: Dietary perspective of a global menace.

Obesity is considered a major public health concern throughout the world among children, adolescents, as well as adults and several therapeutic, preventive and dietary interventions are available. In addition to life style changes and medical interventions, significant milestones have been achieved in the past decades in the development of several functional foods and dietary regimens to reduce this menace. Being a multifactorial phenomenon and related to increased fat mass that adversely affects health, obesity has been associated with the development of several other co-morbidities. A great body of research and strong scientific evidence identifies obesity as an important risk factor for onset and progression of several neurological disorders. Obesity induced dyslipidaemia, metabolic dysfunction, and inflammation are attributable to the development of a variety of effects on central nervous system (CNS). Evidence suggests that neurological diseases such as Parkinson's disease and Alzheimer's disease could be initiated by various metabolic changes, related to CNS damage, caused by obesity. These metabolic changes could alter the synaptic plasticity of the neurons and lead to neural death, affecting the normal physiology of CNS. Dietary intervention in combination with exercise can affect the molecular events involved in energy metabolism and synaptic plasticity and are considered effective non-invasive strategy to counteract cognitive and neurological disorders. The present review gives an overview of the obesity and related neurological disorders and the possible dietary interventions.

Cross-sectional study of the hospital management of adult patients with a suspected seizure (EPIC2).

OBJECTIVE: To determine the clinical characteristics, management and outcomes of patients taken to hospital by emergency ambulance after a suspected seizure. DESIGN: Quantitative cross-sectional retrospective study of a consecutive series of patients. SETTING: An acute hospital trust in a large city in England. PARTICIPANTS: In 2012-2013, the regions' ambulance service managed 605 481 emergency incidents, 74 141/605 481 originated from Sheffield (a large city in the region), 2121/74 141 (2.9%) were suspected seizures and 178/2121 occurred in May 2012. We undertook detailed analysis of the medical records of the 91/178 patients who were transported to the city's acute hospital. After undertaking a retrospective review of the medical records, the best available aetiological explanation for the seizures was determined. RESULTS: The best available aetiological explanation for 74.7% (68/91) of the incidents was an epileptic seizure, 11.0% (10/91) were psychogenic non-epileptic seizures and 9.9% (9/91) were cardiogenic events. The epileptic seizures fall into the following four categories: first epileptic seizure (13.2%, 12/91), epileptic seizure with a historical diagnosis of epilepsy (30.8%, 28/91), recurrent epileptic seizures without a historical diagnosis of epilepsy (20.9%, 19/91) and acute symptomatic seizures (9.9%, 9/91). Of those with seizures (excluding cardiogenic events), 2.4% (2/82) of patients were seizing on arrival in the Emergency Department (ED), 19.5% (16/82) were postictal and 69.5% (57/82) were alert. 63.4% (52/82) were discharged at the end of their ED attendance and 36.5% (19/52) of these had no referral or follow-up. CONCLUSIONS: Most suspected seizures are epileptic seizures but this is a diagnostically heterogeneous group. Only a small minority of patients require emergency medical care but most are transported to hospital. Few patients receive expert review and many are discharged home without referral to a specialist leaving them at risk of further seizures and the associated morbidity, mortality and health services costs of poorly controlled epilepsy.

A multicentred cohort evaluation of a chitosan gelling fibre dressing.

A multicentre cohort evaluation was undertaken by 15 clinicans in 11 centres across Staffordshire community care on chitosan gelling fibre dressing (Kytocel(®)). The aim of this evaluation was to examine whether the new fibre dressing improved healing outcomes for patients with chronic non-healing wounds of 6 weeks or more, observations were made regarding tissue type, fluid handling, haemostasis in bleeding friable wounds and increased granulation. Quality of life observations regarding leaking, strikethrough, pain, wear time and malodour were observed over a 4-week period or until healed. A total of 18 patients took part; 13 women and 5 men, with a mean age of 60.7 years. Fifteen (83%) had wounds in excess of 12 weeks and nine (50%) received care within wound clinics compared to home visits. Eleven (61%) patients' wounds healed within 4 weeks. A number of quality-of-life issues were addressed successfully, namely reduction in malodour and fluid handling. Sixteen (89%) rated the dressing's overall performance as very good to good.

Boceprevir early-access for advanced-fibrosis/cirrhosis in Asia-Pacific hepatitis C virus genotype 1 non-responders/relapsers.

AIM: To examined the efficacy and safety of treatment with boceprevir, PEGylated-interferon and ribavirin (PR) in hepatitis C virus genotype 1 (HCVGT1) PR treatment-failures in Asia. METHODS: The Boceprevir Named-Patient Program provided boceprevir to HCVGT1 PR treatment-failures. Participating physicians were invited to contribute data from their patients: baseline characteristics, on-treatment responses, sustained virological response at week 12 (SVR12), and safety were collected and analysed. Multivariate analysis was performed to determine predictors of response. RESULTS: 150 patients were enrolled from Australia, Malaysia, Singapore and Thailand (Asians = 86, Caucasians = 63). Overall SVR12 was 61% (Asians = 59.3%, Caucasians = 63.5%). SVR12 was higher in relapsers (78%) compared with non-responders (34%). On-treatment responses predicted SVR, with undetectable HCVRNA at week 4, 8 and 12 leading to SVR12s of 100%, 87%, and 82% respectively, and detectable HCVRNA at week 4, 8 and 12, leading to SVR12s of 58%, 22% and 6% respectively. Asian patients were similar to Caucasian patients with regards to on-treatment responses. Patients with cirrhosis (n = 69) also behaved in the same manner with regards to on-treatment responses. Those with the IL28B CC genotype (80%) had higher SVRs than those with the CT/TT (56%) genotype (P = 0.010). Multivariate analysis showed that TW8 and TW12 responses were independent predictors of SVR. Serious adverse events occurred in 18.6%: sepsis (2%), decompensation (2.7%) and blood transfusion (14%). Discontinuations occurred in 30.7%, with 18.6% fulfilling stopping rules. CONCLUSION: Boceprevir can be used successfully in PR treatment failures with a SVR12 > 80% if they have good on-treatment responses; however, discontinuations occurred in 30% because of virological failure or adverse events.

Survey of nursing and medical profile prior to deinstitutionalization of a population with profound mental retardation.

During the planning stages of deinstitutionalization, the importance of nursing services must be recognized and given priority consideration in the community placement of persons with serious developmental disabilities. The objective of this study was to survey the medical and nursing profile of a group of nonambulatory, institutionalized individuals with profound mental retardation in anticipation of their nursing and medical needs in the community. Data were collected from the Individual Habilitation Plans of 55 individuals who had resided in a residential facility for individuals with mental retardation and were scheduled for community placement Serious medical problems in decreasing frequency were constipation (96%), seizure disorder (70%), poor dental hygiene (67%), cerebral palsy (62%), scoliosis (61%), contractions (41%), aspiration (44%), skin lesions (40%), and dysphagia (22%). Considering the complexity of health issues encountered in this population, adequate nursing and medical planning are critical to the wellness and successful community placement of a population with special needs.

Energy balance during an ironman triathlon in male and female triathletes.

Energy balance of 10 male and 8 female triathletes participating in an Ironman event (3.8-km swim, 180-km cycle, 42.2-km run) was investigated. Energy intake (EI) was monitored at 7 designated points by dietary recall of food and fluid consumption. Energy expenditure (EE) during cycling and running was calculated using heart rate-VO, regression equations and during swimming by the multiple regression equation: Y = 3.65v+ 0.02W- 2.545 where Yis VO,in L x min(-1), v is the velocity in m s(-1), Wis the body weight in kilograms. Total EE (10,036 +/- 931 and 8,570 +/- 1,014 kcal) was significantly greater than total EI (3,940 +/- 868 and 3,115 +/- 914 kcal, p <.001) for males and females, respectively, although energy balance was not different between genders. Finishing time was inversely related to carbohydrate (CHO) intake (g x kg(-1) x h(-1)) during the marathon run for males (r = -.75,p <.05), and not females, suggesting that increasing CHO ingestion during the run may have been a useful strategy for improving Ironman performance in male triathletes.