Improving delirium screening in older adults at the Royal United Hospital, Bath.

AIMS/BACKGROUND: Delirium affects around 20% of older inpatients, increasing mortality and length of stay. Around 30% of cases are preventable. The authors sought to determine compliance of the admissions to the Older People's Unit of the Royal University Hospital Bath with the national and internal guidelines for delirium screening and improve its use on admission. METHODS: A total of 60 patients' notes were inspected for compliance. Subsequently, the authors implemented teaching, changed the admission proforma and re-wrote the hospital guidelines for delirium. The notes were rescreened at 6 and 18 months. RESULTS: Initially, 25% of notes met the national standards and 63% met the hospital criteria. At 6 months this was 52% and 82% respectively, and at 18 months it was 41% and 87% respectively. The proportion of patients screened via multiple methods also increased. CONCLUSIONS: There was a sustained improvement in compliance with the national and hospital standards for delirium screening. There was some degradation in the national standard but the proportion of patients meeting the National Institute for Health and Care Excellence standard was still higher than pre-intervention.

Development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity: a discussion paper.

Early in the COVID-19 pandemic there was widespread concern that healthcare systems would be overwhelmed, and specifically, that there would be insufficient critical care capacity in terms of beds, ventilators or staff to care for patients. In the UK, this was avoided by a threefold approach involving widespread, rapid expansion of critical care capacity, reduction of healthcare demand from non-COVID-19 sources by temporarily pausing much of normal healthcare delivery, and by governmental and societal responses that reduced demand through national lockdown. Despite high-level documents designed to help manage limited critical care capacity, none provided sufficient operational direction to enable use at the bedside in situations requiring triage. We present and describe the development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity. The document combines a wide variety of factors known to impact on outcome from critical illness, integrated with broad-based clinical judgement to enable structured, explicit, transparent decision-making founded on robust ethical principles. It aims to improve communication and allocate resources fairly, while avoiding triage decisions based on a single disease, comorbidity, patient age or degree of frailty. It is designed to support and document decision-making. The document has not been needed to date, nor adopted as hospital policy. However, as the pandemic evolves, the resumption of necessary non-COVID-19 healthcare and economic activity mean capacity issues and the potential need for triage may yet return. The document is presented as a starting point for stakeholder feedback and discussion.

Localizing syntactic predictions using recurrent neural network grammars.

Brain activity in numerous perisylvian brain regions is modulated by the expectedness of linguistic stimuli. We leverage recent advances in computational parsing models to test what representations guide the processes reflected by this activity. Recurrent Neural Network Grammars (RNNGs) are generative models of (tree, string) pairs that use neural networks to drive derivational choices. Parsing with them yields a variety of incremental complexity metrics that we evaluate against a publicly available fMRI data-set recorded while participants simply listen to an audiobook story. Surprisal, which captures a word's un-expectedness, correlates with a wide range of temporal and frontal regions when it is calculated based on word-sequence information using a top-performing LSTM neural network language model. The explicit encoding of hierarchy afforded by the RNNG additionally captures activity in left posterior temporal areas. A separate metric tracking the number of derivational steps taken between words correlates with activity in the left temporal lobe and inferior frontal gyrus. This pattern of results narrows down the kinds of linguistic representations at play during predictive processing across the brain's language network.

Improving recruitment of older people to research through good practice.

There is widespread evidence both of the exclusion of older people from clinical research, and of under-recruitment to clinical trials. This review and opinion piece provides practical advice to assist researchers both to adopt realistic, achievable recruitment rates and to increase the number of older people taking part in research. It analyses 14 consecutive recently published trials, providing the number needed to be screened to recruit one older participant (around 3:1), numbers excluded (up to 49%), drop out rates (5-37%) and whether the planned power was achieved. The value of planning and logistics are outlined, and approaches to optimising recruitment in hospital, primary care and care home settings are discussed, together with the challenges of involving older adults with mental incapacity and those from minority groups in research. The increasingly important task of engaging older members of the public and older patients in research is also discussed. Increasing the participation of older people in research will improve the generalisability of research findings and inform best practice in the clinical management of the growing older population.

Rehabilitation of older patients: day hospital compared with rehabilitation at home. Clinical outcomes.

OBJECTIVES: to test the hypothesis that older people and their informal carers are not disadvantaged by home-based rehabilitation (HBR) relative to day hospital rehabilitation (DHR). DESIGN: pragmatic randomised controlled trial. SETTING: four geriatric day hospitals and four home rehabilitation teams in England. PARTICIPANTS: eighty-nine patients referred for multidisciplinary rehabilitation. The target sample size was 460. INTERVENTION: multidisciplinary rehabilitation either in the home or in the day hospital. MEASUREMENTS: the primary outcome measure was the Nottingham extended activities of daily living scale (NEADL). Secondary outcome measures included EQ-5D, hospital anxiety and depression scale, therapy outcome measures, hospital admissions and the General Health Questionnaire for carers. RESULTS: at the primary end point of 6 months NEADL scores were not significantly in favour of HBR cf. DHR; mean difference -2.139 (95% confidence interval -6.87 to 2.59, P = 0.37). A post hoc analysis suggested non-inferiority for HBR for NEADL but there was considerable statistical uncertainty. CONCLUSION: taken together the statistical analyses and lack of power of the trial outcomes do not provide sufficient evidence to conclude that patients in receipt of HBR are disadvantaged compared with those receiving DHR.

Short-range remote detection of liquid surface contamination by active imaging Fourier transform spectrometry.

An imaging Fourier transform spectrometer developed at TUHH was used for short-range remote detection and identification of liquids on surfaces. The method is based on the measurement of infrared radiation emitted and reflected by the surface and the liquid. A radiative transfer model that takes both the real and imaginary parts of the refractive index of the materials into account has been developed. The model is applied for the detection and identification of potentially hazardous liquids. Measurements of various liquids on diverse surfaces were performed. The measured spectra depend on the optical properties of the background surface. However, using the radiative transfer model, automatic remote detection and identification of the liquids is possible. The agreement between measured spectra and spectra calculated using the radiative transfer model is excellent.

Design of a broadband UV-visible alpha-barium borate polarizer.

Until recently, the construction of polarizers for operation below approximately 260 nm were limited to materials such as magnesium fluoride and crystalline quartz. These materials have a much smaller birefringence than calcite, but unlike calcite they have good transmission below 200 nm. These materials are, however, not well suited for Glan-Taylor-type polarizer designs, as they do not produce a large angular separation of the polarized components. A new material, a-barium borate, has recently become available, which transmits to just below 200 nm and has a birefringence that approaches that of calcite. We analyze the performance of various polarizer designs that use this material. Results are presented that compare theory with experimental investigation of a manufactured device.

Low-loss ultrabroadband 90 degree optical rotator with collinear input and output beams.

An achromatic device to rotate optical polarization by 90 degrees is described. This is based on a series of reflecting surfaces that rotates incoming light about the optical axis and translates it such that the exiting light is collinear. Polarization rotation is achieved by rotation of the optical beam, as opposed to the more common approach of phase retardation by use of birefringent elements. For broadband operation from the UV to the near infrared, the device was constructed by use of total internal reflection in three fused-silica glass components. Losses are minimized with interstitial surfaces designed to be angled close to Brewster's angle.