Turns while walking among individuals with Parkinson's disease following overground locomotor training: A pilot study.

BACKGROUND: Individuals with Parkinson's disease are challenged in making turns while walking, evidenced by reduced intersegmental coordination and reduced dynamic postural stability. Although overground locomotor training previously improved ambulation among people with Parkinson's disease, its effect on walking turns remained unknown. We sought to understand the effects of overground locomotor training on walking turns among individuals with mild-Parkinson's disease. METHODS: Twelve participants with Parkinson's (7 Males/5 Females; Age: 68.5 ± 6.4 years) completed twenty-four sessions lasting approximately 60 min and over 12-15 weeks. Baseline and follow-up assessments included the ten-minute walk test using wearable sensors. Primary outcomes included changes to intersegmental coordination, measured by peak rotation and normalized peak rotation, and dynamic postural stability, measured by peak turn velocities in the frontal and transverse planes. Statistical analysis included one-tailed paired t-tests and Cohen's d effect sizes with α = 0.05. FINDINGS: No effects of overground locomotor training on mean peak thoracic rotation (+0.23 ± 4.24°; Cohen's d = 0.05; P = 0.45) or mean normalized peak thoracic rotation (-0.59 ± 5.52 (unitless); Cohen's d = 0.10; P = 0.45) were observed. Moderate and small effects of overground locomotor training were observed on mean peak turn velocities in the frontal (+1.59 ± 2.18°/s; Cohen's d = 0.43; P = 0.01) and transverse planes (+0.88 ± 3.18°/s; Cohen's d = 0.25; P = 0.18). INTERPRETATION: This pilot study provides preliminary evidence suggesting that individuals with mild-Parkinson's moderately improved frontal plane dynamic postural stability after overground locomotor training, likely attenuating the perturbations experienced while turning. CLINICAL TRIAL REGISTRATION: NCT03864393.

A short overview of bubbles in foods and chocolate.

The incorporation of bubbles in foods has created a positive market response from consumers since their first introduction over 70 years ago and has resulted in an expanding market over this period. However, although the physics and chemistry of most ingredients in commercial food products are reasonably well understood, the behaviour of bubbles in foods are much less established and their behaviour not fully appreciated. In fact, bubbles are perhaps the least studied of all food ingredients even though aeration is still one of the fastest growing unit operations in processing. Although many of these manufactured aerated food products are perceived as lighter with lower calorific values, problems in manufacturing remain even today and it is generally difficult to optimize the size, the size distribution, the deviation the from spherical shapes and the stability of the bubbles during the different stages of the processing. In this review, we discuss the dispersion of the various food ingredients and the different processes involved in introducing bubbles into the melt, producing well dispersed multiphase systems. The second part of this review focusses on aerated chocolate and the above aspects are particularly important and are discussed in some detail since it has been well established that the bubble size and size distribution can influence the texture, the mouthfeel, the crispness, the melting temperature, and the brittleness of the product. Understanding the science involved in the transformation from the liquid state containing dispersed bubbles to a solid chocolate foam, stabilization of the bubbles and the control of the bubble size are highlighted. Although CO2 is usually used to generate bubbles in chocolate, several different gases including N2O, Ar and N2 have also been evaluated. One of the research aims of food companies is to improve control over the stability of the systems. This has been investigated with respect to drainage, by carrying out experiments under zero gravity conditions.

Long-term trends in critical care admissions in Wales*.

As national populations age, demands on critical care services are expected to increase. In many healthcare settings, longitudinal trends indicate rising numbers and proportions of patients admitted to ICU who are older; elsewhere, including some parts of the UK, a decrease has raised concerns with regard to rationing according to age. Our aim was to investigate admission trends in Wales, where critical care capacity has not risen in the last decade. We used the Secure Anonymised Information Linkage Databank to identify and characterise critical care admissions in patients aged ≥ 18 years from 1 January 2008 to 31 December 2017. We categorised 85,629 ICU admissions as youngest (18-64 years), older (65-79 years) and oldest (≥ 80 years). The oldest group accounted for 15% of admissions, the older age group 39% and the youngest group 46%. Relative to the national population, the incidence of admission rates per 10,000 population in the oldest group decreased significantly over the study period from 91.5/10,000 in 2008 to 77.5/10,000 (a relative decrease of 15%), and among the older group from 89.2/10,000 in 2008 to 75.3/10,000 in 2017 (a relative decrease of 16%). We observed significant decreases in admissions with high comorbidity (modified Charlson comorbidity index); increases in the proportion of older patients admitted who were considered 'fit' rather than frail (electronic frailty index); and decreases in admissions with a medical diagnosis. In contrast to other healthcare settings, capacity constraints and surgical imperatives appear to have contributed to a relative exclusion of older patients presenting with acute medical illness.

Reliability of frailty assessment in the critically ill: a multicentre prospective observational study.

Demand for critical care among older patients is increasing in many countries. Assessment of frailty may inform discussions and decision making, but acute illness and reliance on proxies for history-taking pose particular challenges in patients who are critically ill. Our aim was to investigate the inter-rater reliability of the Clinical Frailty Scale for assessing frailty in patients admitted to critical care. We conducted a prospective, multi-centre study comparing assessments of frailty by staff from medical, nursing and physiotherapy backgrounds. Each assessment was made independently by two assessors after review of clinical notes and interview with an individual who maintained close contact with the patient. Frailty was defined as a Clinical Frailty Scale rating > 4. We made 202 assessments in 101 patients (median (IQR [range]) age 69 (65-75 [60-80]) years, median (IQR [range]) Acute Physiology and Chronic Health Evaluation II score 19 (15-23 [7-33])). Fifty-two (51%) of the included patients were able to participate in the interview; 35 patients (35%) were considered frail. Linear weighted kappa was 0.74 (95%CI 0.67-0.80) indicating a good level of agreement between assessors. However, frailty rating differed by at least one category in 47 (47%) cases. Factors independently associated with higher frailty ratings were: female sex; higher Acute Physiology and Chronic Health Evaluation II score; higher category of pre-hospital dependence; and the assessor having a medical background. We identified a good level of agreement in frailty assessment using the Clinical Frailty Scale, supporting its use in clinical care, but identified factors independently associated with higher ratings which could indicate personal bias.

Incidence and risk factors for alopecia in survivors of critical illness: A multi-centre observational study.

PURPOSE: To investigate the incidence, nature and risk factors for patient-reported alopecia in survivors of critical illness. MATERIALS AND METHODS: A multi-centre, mixed methods observational study in the intensive care units (ICU) of ten hospitals in Wales. All patients with an ICU stay of 5 days or more, able to give consent were included. Demographic variables and risk factors were collected. A pre-designed survey was completed at three months post-ICU discharge. Statistical analysis included numbers and percentages (categorical variables) and medians and interquartile ranges (continuous variables). Comparisons between patients with and without alopecia were made using Fisher's Exact test (categorical variables) and Mann Whitney U test (continuous variables). Multivariate logistic regression analysis was used to determine the risk factors for alopecia. RESULTS: The survey was completed by 123 patients with alopecia reported in 44 (36%) patients. The only risk factor for alopecia on analysis was sepsis / septic shock (p < .001; OR: 5.1, 95%CI: 2.1-12.4). CONCLUSIONS: Limited research exists examining the incidence, nature and risk factors for patient-reported alopecia in adult survivors of critical illness. The results of this study highlight the need to discuss the potential for alopecia with survivors of critical illness, who had sepsis / septic shock.

Defining sepsis on the wards: results of a multi-centre point-prevalence study comparing two sepsis definitions.

Our aim was to prospectively determine the predictive capabilities of SEPSIS-1 and SEPSIS-3 definitions in the emergency departments and general wards. Patients with National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled over a 24-h period in 13 Welsh hospitals. The primary outcome measure was mortality within 30 days. Out of the 5422 patients screened, 431 fulfilled inclusion criteria and 380 (88%) were recruited. Using the SEPSIS-1 definition, 212 patients had sepsis. When using the SEPSIS-3 definitions with Sequential Organ Failure Assessment (SOFA) score ≥ 2, there were 272 septic patients, whereas with quickSOFA score ≥ 2, 50 patients were identified. For the prediction of primary outcome, SEPSIS-1 criteria had a sensitivity (95%CI) of 65% (54-75%) and specificity of 47% (41-53%); SEPSIS-3 criteria had a sensitivity of 86% (76-92%) and specificity of 32% (27-38%). SEPSIS-3 and SEPSIS-1 definitions were associated with a hazard ratio (95%CI) 2.7 (1.5-5.6) and 1.6 (1.3-2.5), respectively. Scoring system discrimination evaluated by receiver operating characteristic curves was highest for Sequential Organ Failure Assessment score (0.69 (95%CI 0.63-0.76)), followed by NEWS (0.58 (0.51-0.66)) (p < 0.001). Systemic inflammatory response syndrome criteria (0.55 (0.49-0.61)) and quickSOFA score (0.56 (0.49-0.64)) could not predict outcome. The SEPSIS-3 definition identified patients with the highest risk. Sequential Organ Failure Assessment score and NEWS were better predictors of poor outcome. The Sequential Organ Failure Assessment score appeared to be the best tool for identifying patients with high risk of death and sepsis-induced organ dysfunction.

An innovative solution to raise public awareness using a mobile colorectal clinic - The 'bowel bus'.

INTRODUCTION: Colorectal cancer is the fourth most common cancer in the United Kingdom; however, figures show that the uptake for bowel cancer screening lags behind other cancer screening programmes. METHODS: This is a report of a multi-staged development of an outreach colorectal clinical community service provided through a Mobile Unit (a Bowel Bus). The unit delivers a one-stop colorectal clinic that provides a rapid access pathway to members of the public who have concerns about, or symptoms of, bowel cancer. The aims of the project were to increase public awareness about colorectal cancer and to provide an outreach clinic as a supplement to the hospital based colorectal clinic. This service is a result of collaborative efforts between Tenovus Cancer Care (TCC) and the colorectal surgery department of the local NHS Hospital. RESULTS: During one year, the Bowel Bus has provided services to 772 members of the local community. 244 patients were examined by the colorectal nurse specialist including 66 drop-in patients and 135 patients referred by the GPs. The service led to decrease in the waiting list for routine referrals to be seen in the colorectal clinic at the hospital from a mean of 10.5 weeks-5.9 weeks. A feedback questionnaire from 180 patients, used to audit the quality of the service, has confirmed an overwhelming satisfaction with the service. CONCLUSION: The Mobile Unit is a novel solution to addressing the ever increasing demand for specialist outpatient services without compromising the quality of care whilst enhancing the patient experience.

Tracheal stenosis following percutaneous dilatational tracheostomy using the single tapered dilator: an MRI study.

Despite widespread adoption of percutaneous dilatational tracheostomy within the critical care setting, there is still uncertainty regarding long-term complications, particularly in relation to missed or subclinical tracheal stenosis. In this study, all patients underwent tracheostomy using a single tapered dilator ≥ three months prior to enrollment and were evaluated using magnetic resonance imaging, spirometry and questionnaire. Tracheal area was recorded and deemed to be stenotic if a reduction of ≥10% was found. Fifty patients underwent magnetic resonance imaging and 49 attended for interview. Five patients were diagnosed with tracheal stenosis-none were symptomatic. Six of the 50 tracheostomies were technically difficult. Spirometry was not predictive of stenosis. A post critical care exercise tolerance of less than 100 metres was found in four tracheal stenosis patients. The prevalence of subclinical tracheal stenosis following percutaneous tracheostomy is low, with limited clinical significance. No patients required corrective surgery for tracheal stenosis. Routine airway follow-up in asymptomatic patients appears to be unwarranted.

Nature of child sexual abuse and psychopathology in adult survivors: results from a clinical sample in Scotland.

The relationship between history of childhood sexual abuse and psychopathology in adult life is well established. However, understanding of the mechanisms by which abuse exerts its effects is limited. To our knowledge, this is the first study which investigates the relationship between a wide range of sexual abuse characteristics (i.e. age at onset, frequency of assaults, number of perpetrators and their relationship to the victim) and the severity of psychopathological disorders in a large sample of adult child sexual abuse (CSA) survivors who attended a specialist Psychotherapy Service for CSA survivors. CSA survivors in our study experienced severe sexual assault(s) in their early years and presented with severe pathology which could suggest a strong causal link. However, none of the examined trauma characteristics significantly predicted severity of psychopathology. This may suggest that for severely disordered, treatment-seeking CSA survivors post-abuse psychopathology could be caused by other factors. The study adds to the growing body of evidence suggesting that CSA effects may be dependent on factors which are not necessarily related to the nature of sexual abuse. The study findings will help improve clinicians' insight into the determinants of psychopathology.

Short course antibiotic therapy for Gram-negative hospital-acquired pneumonia in the critically ill.

Hospital-acquired pneumonia (HAP) is a common cause of morbidity and mortality in the critically ill, yet the optimal duration of antibiotic therapy is unknown. Too short a course may lead to treatment failure, whereas too long a course may lead to increased antibiotic resistance, antibiotic-related morbidity and increased costs. Standard duration of antibiotic therapy for Gram-negative (GN-)HAP at our institution is 5 days, significantly shorter than advocated in many current guidelines. We performed a retrospective review of all cases of GN-HAP on our critical care unit fulfilling clinical and microbiological criteria to investigate recurrence rate and mortality following short course antibiotic therapy. Seventy-nine eligible patients with GN-HAP were identified. Of these, 79% were receiving mechanical respiratory support at diagnosis; 42% had GN-HAP due to non-fermenting Gram-negative bacilli (NF-GNB) and 72% were treated with the recommended 5 day course of antibiotics. Two patients had clear evidence of non-resolution of pneumonia after 5 days of therapy. Overall recurrence rate was 14%, with relapse rates significantly higher among patients with NF-GNB when compared to patients with other Gram-negative organisms (17% vs 2%; P=0.03). The overall recurrence rate was no higher than rates reported in earlier studies (17-41%). Critical care mortality (34.2%) was also not in excess of previously reported values (18-57%). In this limited study, use of a 5 day course of appropriate antibiotics for GN-HAP does not appear to increase risk of recurrence or mortality when pneumonia resolution has been achieved prior to the cessation of therapy.

Prevalence of chronic viral hepatitis in people of south Asian ethnicity living in England: the prevalence cannot necessarily be predicted from the prevalence in the country of origin.

The prevalence of hepatitis B and hepatitis C in immigrant communities is unknown. Immigrants from south Asia are common in England and elsewhere, and the burden of viral hepatitis in these communities is unknown. We aimed to determine the prevalence of viral hepatitis in immigrants from south Asia living in England, and we therefore undertook a community-based testing project in such people at five sites in England. A total of 4998 people attending community centres were screened for viral hepatitis using oral fluid testing. The overall prevalence of anti-hepatitis C virus (HCV) in people of south Asian origin was 1.6% but varied by country of birth being 0.4%, 0.2%, 0.6% and 2.7% in people of this ethnic group born in the UK, India, Bangladesh and Pakistan, respectively. The prevalence of hepatitis B surface antigen was 1.2%-0.2%, 0.1%, 1.5% and 1.8% in people of this ethnic group born in the UK, India, Bangladesh and Pakistan, respectively. Analysis of risk factors for HCV infection shows that people from the Pakistani Punjab and those who have immigrated recently are at increased risk of infection. Our study suggests that migrants from Pakistan are at highest risk of viral hepatitis, with those from India at low risk. As prevalence varies both by country and region of origin and over time, the prevalence in migrant communities living in western countries cannot be easily predicted from studies in the country of origin.

Value of targeting at-risk populations at outreach venues: findings from a local sauna.

An assessment of the need to increase access to an outreach venue, the local sauna in Walsall, UK, frequented only by men who have sex with men, was undertaken. A case-notes review of the clients who attended the monthly outreach sessions at the sauna in the year 2007 was performed. Among the 287 men seen at the 12 outreach sessions, 37% had a sexually transmitted infection (STI). Of those tested positive, 88% had never had a previous STI. Twenty-one men had syphilis and a further six tested positive for HIV. Hepatitis B vaccination was completed for 41% of the clients seen. Those who tested positive for an STI said they would not have attended a conventional setting but accepted screening at the sauna. This confirmed the need to increase access at this outreach venue, and further funding has now been provided to have outreach sessions twice a month.

Diagnostic specificity of a real-time RT-PCR in cattle for foot-and-mouth disease and swine for foot-and-mouth disease and classical swine fever based on non-invasive specimen collection.

Foot-and-mouth disease virus (FMDV) and classical swine fever virus (CSFV) are highly contagious and can cause great economic losses when introduced into disease-free regions. Accurate estimates of diagnostic specificity (Sp) are important when considering the implementation of surveillance for these agents. The purpose of this study was to estimate diagnostic Sp of a real-time reverse-transcriptase PCR assay developed for detection of FMDV in cattle and domestic swine and CSFV in domestic swine based on non-invasive specimen collection. One thousand and eighty-eight range beef cattle were sampled from thirteen geographic locations throughout Texas. One thousand and one hundred market hogs and cull sows were sampled. Results for both FMDV and CSFV were considered positive if amplification occurred at or before 40 PCR cycles, inconclusive between 40 and 45 cycles and negative otherwise. Ten cattle had nonspecific PCR amplifications for FMDV, but none were classified as positive and only one as inconclusive. Specificity (95% confidence interval) was estimated as 100% (99.7, 100). There were 19 nonspecific PCR amplifications for FMDV in sampled swine with 1 classified as positive, 6 as inconclusive, and 12 as negative. Specificity (95% confidence interval) was estimated as 99.9% (99.5, 100). There were 21 nonspecific PCR amplifications for CSFV, and 1 was classified as positive. Specificity (95% confidence interval) was estimated as 99.9% (99.5, 100). These assays have high Sp, but nonspecific PCR amplifications can occur.

Foaming in chemical surfactant free aqueous dispersions of anatase (titanium dioxide) particles.

Steady-state dynamic aqueous foams were generated from surfactant-free dispersion of aggregated anatase nanoparticles (in the micrometer size range). In order to tune the particle surfaces, to ensure a critical degree of hydrophobicity (so that they disperse in water and generate foam), the particles were subjected to low-temperature plasma treatment in the presence of a vapor-phase silane coupling agents. From ESCA it was shown that hydrophobization only occurred at a small number of surface sites. Foamability (foam generation) experiments were carried out under well-defined conditions at a range of gas flow rates using the Bikermann Foaming Column.1 The volume of the steady-state foams was determined under constant gas flow conditions, but on removing the gas flow, transient foams with short decay times (<5 s) were observed. The foamability of the steady-state foams was found to be dependent on (a) the time of plasma treatment of the particles (surface hydrophobicity), (b) the particle concentration in the suspension, and (c) the state of dispersion of the particles. High foamability was promoted in the neutral pH regions where the charged particles were highly dispersed. In the low and high pH regions where the particles were coagulated, the foamability was considerably reduced. This behavior was explained by the fact that the large coagula were less easily captured by the bubbles and more easily detached from the interface (during the turbulent foaming conditions) than individual dispersed particles.

Syphilis outbreak in Walsall, UK: lessons for control and prevention.

An assessment of risk-taking behaviour among men who have sex with men (MSM) attending a sauna venue was undertaken, using a standardized questionnaire, after which outreach screening was introduced targeting MSM. The epidemiology of the continuing outbreak of syphilis was reviewed to determine the factors driving the outbreak and assess the benefit of continuing outreach screening. Findings among the 163 respondents at the sauna included a high rate of casual sex and a tendency not to disclose HIV status. Over 12 months, 51 cases of early syphilis were recorded. Our review showed a decline in incidence in MSM after outreach screening, but an increase in heterosexual spread. Given the frequent anonymous nature of syphilis transmission, traditional contact tracing is ineffective. Outreach screening is required at gay venues and other community settings to target at-risk populations.

Influence of soybean hull supplementation on rumen fermentation and digestibility in steers consuming freshly clipped, endophyte-infected tall fescue.

Six steers (288.6 +/- 2.1 kg of BW) fitted with rumen and duodenal cannulas were used in a crossover design to evaluate intake, rumen fermentation, and site of nutrient digestion of freshly clipped, endophyte-infected (E+) Kentucky 31 tall fescue with or without soybean hull (SH) supplementation at 0.60% of BW (OM basis). Steers were placed in metabolism units within an environmentally controlled room and provided with free-choice access to fresh forage, water, and a vitamin/mineral supplement. The spring growth of E+ tall fescue was harvested daily during the experiment. Supplement was fed at 0700 with approximately 65% of the estimated daily forage. To maintain a fresh forage supply, additional forage was stored in a cooler and fed at 1900. Periods were 21 d with 14 d of adaptation and 7 d of digesta sample collection. Chromic oxide was used as a marker of duodenal digesta flow. Duodenal samples were taken 4 times daily with times shifting by 1 h each day to represent all 24 h of a day. Treatments were considered significant at P < 0.05. Supplementation of SH decreased forage OM intake from 1.64 to 1.41% of BW but increased total OM intake from 1.64 to 2.01% of BW. Apparent percentages (53.1%) and quantities (2,786 g/d) of rumen OM disappearance were not affected by supplementation. Percentages of total tract OM disappearance were not different (70.8%). Percentages of apparent rumen NDF disappearance also were not different (65.6%). Percentages of N disappearance were not different. Supplementation of SH resulted in increased total N (34.1 g/d) and microbial N (17.1 g/d) flowing to the duodenum. Rumen pH (6.5) was not affected, and rumen ammonia concentrations exhibited a time x treatment interaction in which SH decreased ammonia for 12 h after supplementation. Total VFA concentrations (103.9 mM) were unaffected. Liquid dilution rate (12.7%/h) and rumen OM fill (4.3 kg) were not different between treatments. Supplementation of SH at a rate of 0.60% of BW (OM basis) to calves consuming fresh E+ tall fescue decreased forage consumption but resulted in greater total intake, greater flow of N to the duodenum, and increased total tract OM disappearance.

The crisis in sexual health and developing genitourinary medicine services: lessons from a primary care trust.

The House of Commons Health Select Committee recently described a national crisis in sexual health. Alarmed by dramatic increases in the rates of sexually transmitted infections (STIs) and appalled by over-stretched, under-resourced genitourinary (GU) medicine services, the committee has called for urgent action. The increasing rates of STIs locally, a significant cluster of syphilis cases, and an over-burdened GU medicine service prompted Walsall primary care trust to undertake an evaluation of local service provision. The results were used to inform the development of GU medicine services locally and Walsall's sexual health strategy. This paper reports the results of the evaluation and the implications for service development. The Walsall GU medicine service was evaluated using three approaches, based on standards for GU medicine service provision identified from the literature. Routine data were used to analyse trends in STIs and service activity, including access times. These data further informed the evaluation process. Local stakeholder views on GU medicine service provision were sought using semi-structured interviews. Most standards relating to the provision of core services, including those for the management of patients with HIV infection, were met. High levels of patient satisfaction were reported. However, under-staffing, inadequate clinic facilities, and limited joint working with other agencies were highlighted as key concerns. Tackling sexual health inequalities and improving the sexual health of the population requires investment in resources and manpower, improved partnership working, and configuring services around the needs of patients. In addition, and perhaps most importantly, it will require a shift in how both health professionals and the public perceive and utilize sexual health services.

Fatty acid and sensory characteristics of beef from three biological types of cattle grazing cool-season forages supplemented with soyhulls.

Over two consecutive years, the effects of allocating divergent biological types of cattle (n=107) to fescue pasture without supplementation, or fescue or orchardgrass pasture with soyhull supplementation on chemical, fatty acid and sensory characteristics were investigated. Cattle from the two supplemented treatments produced beef that had increased (P<0.05) percentage lipid and decreased (P<0.05) polyunsaturated and n-3 fatty acids compared to the control. However, the n-6 to n-3 ratio was still less than four in beef from the supplemented cattle. Additionally, supplementation did not decrease (P>0.05) the CLA present in the longissimus, which can commonly occur when forage-fed cattle are supplemented concentrates. Although supplementation did not impact (P>0.05) Warner-Bratzler shear force or tenderness, supplementation of soyhulls reduced (P<0.05) the grassy flavor intensity of rib steaks when compared to the control. Biological type did not have a significant influence on most traits analyzed in this study. These results suggest that supplementation of soyhulls to cattle grazing forage can reduce grassy flavor intensity without decreasing CLA proportions, but can reduce the n-3 fatty acid proportions present in the longissimus.