The impact of a cognitive impairment support program on patients in an acute care setting: a pre-test post-test intervention study.

BACKGROUND: Patients with cognitive impairment are at greater risk of hospital acquired complications, longer hospital stays, and poor health outcomes compared to patients without cognitive impairment. The Cognitive Impairment Support Program is a multi-disciplinary approach to improve screening rates and awareness of patients with cognitive impairment and guide clinician response and communication during their hospitalisation to improve health outcomes. OBJECTIVE: This study evaluated the impact of implementing the Cognitive Impairment Support Program on patient hospital acquired complications, patient reported quality of life and staff satisfaction in an outer metropolitan hospital. DESIGN: A pre-test post-test design was used to collect data in two 6-month time periods between March 2020 and November 2021. PARTICIPANTS: Patients aged ≥ 65 years, admitted to a participating ward for > 24 h. INTERVENTION: The Cognitive Impairment Support Program consisted of four components: cognitive impairment screening, initiation of a Cognitive Impairment Care Plan, use of a Cognitive Impairment Identifier and associated staff education. MEASURES: The primary outcome was hospital acquired complications experienced by patients with cognitive impairment identified using clinical coding data. Secondary outcomes were patient quality of life and a staff confidence and perceived organisational support to care for patients with cognitive impairment. RESULTS: Hospital acquired complication rates did not vary significantly between the two data collection periods for patients experiencing cognitive impairment with a 0.2% (95% confidence interval: -5.7-6.1%) reduction in admissions with at least one hospital acquired complication. Patients in the post intervention period demonstrated statistically significant improvements in many items in two of the Dementia Quality of Life Measure domains: memory and everyday life. The staff survey indicated statistically significant improvement in clinical staff confidence to care for patients with cognitive impairment (p = 0.003), satisfaction with organisational support for patients (p = 0.004) and job satisfaction (p ≤ 0.001). CONCLUSION: This study provides evidence that a multicomponent Cognitive Impairment Support Program had a positive impact on staff confidence and satisfaction and patient quality of life. Broader implementation with further evaluation of the multicomponent cognitive impairment intervention across a range of settings using varied patient outcomes is recommended.

Occurrence and distribution of microplastics and polychlorinated biphenyls in sediments from the Qiantang River and Hangzhou Bay, China.

Rivers are important routes for sea-bound microplastics. Thus, this study investigated the occurrences and distributions of microplastics and polychlorinated biphenyls (PCBs) in sediment samples from the Qiantang River (QR) and Hangzhou Bay (HZ) and analyzed the correlation between microplastics and PCBs. A total of 15 sampling sites were selected, including eight from the QR (i.e., four in the Tonglu area and four in the Fuyang area), two from the Andong salt marsh (ASM; located in a hydrodynamic turning point of the HZ), and five from HZ. The mean microplastic abundance was highest in the QR, followed by HZ and ASM, with 0.23 ± 0.06, 0.18 ± 0.05, and 0.15 ± 0.03 particles/g sediment, respectively. Cluster analysis demonstrated that fragments and fibers may have originated from domestic sewage inputs to the QR. Spatially, mean PCB concentrations from Tonglu, Fuyang, and HZ were 1.47 ± 0.10, 1.65 ± 0.10, and 1.65 ± 0.09 ng/g sediment, respectively, which were higher than that from the ASM (1.13 ± 0.09 ng/g sediment). The vertical distributions (0-5 cm, 5-10 cm, and 10-15 cm) of microplastics in the sediments at Tonglu and Fuyang decreased with increasing depth, which was opposite to the depth trend of PCB concentrations. Micro-Fourier transform infrared spectroscopy analysis suggested that polyethylene was typically the dominant polymer, accounting for 60 ± 0.08% of the total suspected plastic particles. Microbeads and films showed considerable correlations with both highly and lesser chlorinated PCBs. Overall, our findings highlight the need for routine monitoring of microplastics in China in addition to measures for controlling plastic pollution on a national scale. Further study should ascertain specific sources of microplastics and analyze their adsorption capacity to organic pollutants.

Microplastic pollution in water, sediment, and specific tissues of crayfish (Procambarus clarkii) within two different breeding modes in Jianli, Hubei province, China.

This study investigates the occurrence and distribution of microplastics in water, sediment, and crayfish samples within pond and rice-crayfish co-culture breeding modes in Jianli prefecture, China. Microplastics in environmental and biological samples were systematically extracted by CaCl2 solution, digested by H2O2 and KOH, and identified by µ-FTIR. A cleansing treatment for crayfish was performed in pure water before dissection and microplastic accumulation in different tissues (gill, stomach, gut, and flesh) of non-cleansed and cleansed crayfish were compared. The average microplastic abundances were 1.3 ± 0.1-2.5 ± 0.1 particles/L, 0.03 ± 0.01-0.04 ± 0.02 particles/g, and 0.17 ± 0.07-0.92 ± 0.19 particles/individual in water, sediment, and crayfish samples, respectively. Microplastics were detected in all studied crayfish tissues, except the flesh. There were no significant differences in microplastic abundances in water (P = 0.82), sediment (P = 0.90), and crayfish (P = 0.47 for non-cleansed samples; P = 0.30 for cleansed samples) between two breeding modes despite the detection of relatively higher microplastic abundances in the samples from the pond breeding mode. Microplastic accumulation in non-cleansed crayfish stomachs and guts (0.71 ± 0.18 particles/individual) was higher (P < 0.01) than that recorded in their gills (0.13 ± 0.06 particles/individual). Moreover, microplastics present in the stomachs and guts of cleansed crayfish were significantly less abundant (P < 0.01) than in non-cleansed crayfish, although this was not observed in the gills (P = 0.99). The majority of microplastic particles in this study had fiber-like shapes, blue and transparent colors, a size smaller than 1 mm, and polymer types of PP:PE and PE. The results demonstrate that microplastics in the environment can accumulate in the internal tissues of crayfish, which may pose a potential risk to humans through food consumption without the removal of the gills, stomach, and guts. This study provides valuable information for understanding microplastic accumulation in the different tissues of crayfish and the potential risk of human exposure to microplastics from crayfish as a food supplement.

Interaction between microbial communities and various plastic types under different aquatic systems.

This study investigated the physicochemical surface changes of various plastics caused by indigenous communities. The first invading microbes on plastics in 4 different aquatic communities including seawater, freshwater, marine sediments and lake sediments were developed in microcosm incubation experiments. A mixture of weathered plastics (PE, PS, PET) was incubated with different indigenous communities under their respective habitat simulations. All microbial communities were able to form populations on all plastic surfaces with time-dependent development. Biofilm also affected floatation of plastics and the communities on PE foam (PF) were dominated by genera affiliated with plastic and hydrocarbon degraders. The results showed that indigenous populations were able to degrade plastic pieces and utilize them as carbon sources where the weight of PF was reduced more effectively than PS and PET. Besides, carbonyl groups that were seen with FTIR on initial PF disappeared after microbial treatment along with signs of bioerosion on the plastic surface.

Determination of the mutation spectrum of the EXT1/EXT2 genes in British Caucasian patients with multiple osteochondromas, and exclusion of six candidate genes in EXT negative cases.

We describe here the spectrum and distribution of mutations in the EXT1 and EXT2 genes in the largest reported British Caucasian multiple osteochondromas (MO) population. Furthermore, we report for the first time the screening of the EXT1 and EXT2 promoters, 5'UTRs, and 3'UTRs, and exclude six potential MO candidate genes in individuals without a detectable mutation within the coding region of EXT1 and EXT2. The coding exons of EXT1 and EXT2 were screened in 72 unrelated probands affected with MO. Forty-six different mutations were identified in 56 probands, of which 29 were novel. Mutation in the EXT1 and EXT2 genes each accounted for 50% of the mutations identified. Of the 72 probands, 42 were of British Caucasian descent, which when added to the 41 British Caucasian families previously reported from our total cohort, gave a total of 83 families. This cohort's proportional frequency for EXT1/EXT2 mutation was 53%/47%. We also validated the technique of high-resolution melting analysis in a blind study using 27 unique EXT1 or EXT2 mutations. This technique was found to be sensitive with a detection rate of 100% regarding heterozygote detection for EXT mutation scanning. Furthermore, this technique has a very high throughput and is very cost-effective.

Dengue fever in febrile returning travellers to a UK regional infectious diseases unit.

Background. Dengue occurs in many tourist destinations, and is increasingly imported by returning travellers. We review the epidemiology and clinical features of confirmed dengue in returning travellers presenting to a UK regional infectious diseases unit. Methods. A retrospective, case-record review of febrile returning travellers, admitted to Leicester Royal Infirmary during 2000-2002. The presenting clinical features of patients with positive dengue serology were compared to those who had negative serological tests. Results. Dengue, including two cases of dengue haemorrhagic fever (DHF) and 1 shock syndrome, was diagnosed in 16 of approximately 250 (6.4%) hospitalised returning travellers. 10/16 (62.5%) patients returned from Asia. There was no difference in symptoms between those with or without serological evidence of dengue. Dengue was associated with thrombocytopenia (p=0.001), leucopenia (p=0.03) and elevated alanine transminase (p=0.01). Following multivariate analysis, dengue was associated with first time travel to an endemic area (odds ratio 10.9, 95% CI 1.21-99.9), early onset of symptoms after return (OR 1.91, 95% CI 1.07-3.43), duration of time overseas (OR 1.08, 95% CI 1.01-1.15) and thrombocytopenia (OR 29.4, 95% CI 1.8-494). Conclusions. Dengue is an important cause of illness in hospitalised febrile returning travellers. It should be considered in first-time travellers, with thrombocytopenia and negative malaria films who present with symptoms soon after return.

Randomised controlled trial and health economic evaluation of the impact of diagnostic testing for influenza, respiratory syncytial virus and Streptococcus pneumoniae infection on the management of acute admissions in the elderly and high-risk 18- to 64-year-olds.

BACKGROUND: Western industrialised nations face a large increase in the number of older people. People over the age of 60 years account for almost half of the 16.8 million hospital admissions in England from 2009 to 2010. During 2009-10, respiratory infections accounted for approximately 1 in 30 hospital admissions and 1 in 20 of the 51.5 million bed-days. OBJECTIVE: To determine the diagnostic accuracy and clinical effectiveness and cost-effectiveness of rapid molecular and near-patient diagnostic tests for influenza, respiratory syncytial virus (RSV) and Streptococcus pneumoniae infections in comparison with traditional laboratory culture. METHODS: We carried out a randomised controlled trial (RCT) to evaluate impact on prescribing and clinical outcomes of point-of-care tests (POCTs) for influenza A and B and pneumococcal infection, reverse transcriptase-polymerase chain reaction (RT-PCR) tests for influenza A and B and RSV A and B, and conventional culture for these pathogens. We evaluated diagnostic accuracy of POCTs for influenza and pneumococcal infection, RT-PCR for influenza and sputum culture for S. pneumoniae using samples collected during the RCT. We did a systematic review and meta-analysis of POCTs for influenza A and B. We evaluated ease and speed of use of each test, process outcomes and cost-effectiveness. RESULTS: There was no evidence of association between diagnostic group and prescribing or clinical outcomes. Using PCR as 'gold standard', Quidel Influenza A + B POCT detected 24.4% [95% confidence interval (CI) 16.0% to 34.6%] of influenza infections (specificity 99.7%, 95% CI 99.2% to 99.9%); viral culture detected 21.6% (95% CI 13.5% to 31.6%; specificity 99.8%, 95% CI 99.4% to 100%). Using blood culture as 'gold standard', BinaxNOW pneumococcal POCT detected 57.1% (95% CI 18.4% to 90.1%) of pneumococcal infections (specificity 92.5%; 95% CI 90.6% to 94.1%); sputum culture detected 100% (95% CI 2.5% to 100%; specificity 97.2%, 95% CI 94.3% to 98.9%). Overall, pooled estimates of sensitivity and specificity of POCTs for influenza from the literature were 74% (95% CI 67% to 80%) and 99% (95% CI 98% to 99%), respectively. Median intervals from specimen collection to test result were 15 minutes [interquartile range (IQR) 10-23 minutes) for Quidel Influenza A + B POCT, 20 minutes (IQR 15-30 minutes) for BinaxNOW pneumococcal POCT, 50.8 hours (IQR 44.3-92.6 hours) for semi-nested conventional PCR, 29.2 hours (IQR 26-46.9 hours) for real-time PCR, 629.6 hours (IQR 262.5-846.7 hours) for culture of influenza and 84.4 hours (IQR 70.7-137.8 hours) and 71.4 hours (IQR 69.15-84.0 hours) for culture of S. pneumoniae in blood and sputum, respectively. Both POCTs were rated straightforward and undemanding; blood culture was moderately complex and all other tests were complex. Costs and quality-adjusted life-years (QALYs) of each diagnostic strategy were similar. Incrementally, PCR was most cost-effective (78.3% probability at a willingness to pay of £20,000/QALY). Few patients were admitted within a timescale conducive to treatment with a neuraminidase inhibitor according to National Institute for Health and Care Excellence guidance. LIMITATIONS: The accuracy study was limited by inadequate gold standards. CONCLUSIONS: All tests had limitations. We found no evidence that POCTs for influenza or S. pneumoniae, or PCR for influenza or RSV influenced antimicrobial prescribing or clinical outcomes. The total costs and QALYs of each diagnostic strategy were similar, although, incrementally, PCR was the most cost-effective strategy. The analysis does not support routine use of POCTs for either influenza or pneumococcal antigen for adults presenting with acute cardiopulmonary conditions, but suggests that conventional viral culture for clinical diagnosis should be replaced by PCR. TRIAL REGISTRATION: Current Controlled Trials ISRCTN21521552. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 36. See the NIHR Journals Library website for further project information.

Sequential leukemic infiltration and human herpesvirus optic neuropathy in acute lymphoblastic leukemia.

Leukemic infiltration is a common cause of optic disk swelling in a patient with acute lymphoblastic leukemia (ALL). Recurrence of optic disk swelling in a patient with previous leukemic infiltration carries a grave prognosis when it is associated with recurrent central nervous system disease. We report a case of recurrent swelling of an optic disk in a patient with T-cell ALL who had previously been treated for CNS relapse with optic nerve involvement. In this case the swelling was associated with cytomegalovirus infection and resolved following treatment with antiviral therapy.

The association between ulnar length and forearm movement in patients with multiple osteochondromas.

PURPOSE: To determine the relationship between the length of the ulna as a proportion of height (proportional ulnar length [PUL]), forearm and wrist ranges of motion, and degree of observable deformity in people with hereditary multiple exostoses. METHODS: One hundred forty-two people with hereditary multiple exostoses were examined; 35 were under the age of 15 years and therefore were presumed to be skeletally immature. Elbow, forearm, and wrist motion were measured, and the radius and ulna were palpated for osteochondromas. Ulnar length was estimated as a proportion of height (PUL) in skeletally immature subjects. The relationships between total active motion, number of palpable osteochondromas, and proportional length were examined for one randomly selected limb from each subject. RESULTS: A negative correlation was found between the number of palpable osteochondromas and range of forearm rotation. The degree of forearm motion in those under the age of 15 years was directly related to PUL and indirectly related to the number of palpable osteochondromas. Children whose PUL is within the normal range have a normal range of motion. CONCLUSIONS: In a child with hereditary multiple exostoses affecting the forearm, the PUL is associated with the range of movement and deformity, and it can be a useful adjunct in deciding the appropriate management.