Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

The prevalence of musculoskeletal presentations in general practice: an epidemiological study

Abstract Background It is estimated that 18.8 million people in the United Kingdom are living with a musculoskeletal (MSK) condition. It is a major cause of morbidity and a significant reason for presentation to primary care. Aim To determine the prevalence of MSK conditions presenting for consultation in general practice (GP), and how they are managed. Design and setting Epidemiological study. Method Patient episode consultations were reviewed at an urban community general practice. This involved evaluating morning consultations over a 1-week period from each of January, April, July, and October 2018. This included all the morning consultations from all GPs present. The number of MSK consultations was recorded, and within that the different presentations and their management plan. Results A total of 545 consultations were reviewed, of which 115 were related to an MSK presentation: an overall prevalence of 21.1%. The commonest MSK presentations related to the lumbosacral spine (18.3%) and the knee joint (17.4%). Re-presentations of an existing condition accounted for 73.9% of all MSK consultations. Steroid injections were administered in 33% of knee related consultations. Conclusion MSK presentations account for a large proportion of GP workload, but there is currently no mandatory training in orthopedics as part of the GP curriculum. Structured MSK education for GPs is important and may reduce the burden of re-presentations. Competency in joint injection is also an important skill for GPs. </jats:sec

Rainfall-runoff properties of tephra: Simulated effects of grain-size and antecedent rainfall

Rain-triggered lahars (RTLs) are a significant and often persistent secondary volcanic hazard at many volcanoes around the world. Rainfall on unconsolidated volcaniclastic material is the primary initiation mechanism of RTLs: the resultant flows have the potential for large runout distances (> 100 km) and present a substantial hazard to downstream infrastructure and communities. RTLs are frequently anticipated in the aftermath of eruptions, but the pattern, timing and scale of lahars varies on an eruption-by-eruption and even catchment-by-catchment basis. This variability is driven by a set of local factors including the grain size distribution, thickness, stratigraphy and spatial distribution of source material in addition to topography, vegetation coverage and rainfall conditions. These factors are often qualitatively discussed in RTL studies based on post-eruption lahar observations or instrumental detections. Conversely, this study aims to move towards a quantitative assessment of RTL hazard in order to facilitate RTL predictions and forecasts based on constrained rainfall, grain size distribution and isopach data. Calibrated simulated rainfall and laboratory-constructed tephra beds are used within a repeatable experimental set-up to isolate the effects of individual parameters and to examine runoff and infiltration processes from analogous RTL source conditions. Laboratory experiments show that increased antecedent rainfall and finer-grained surface tephra individually increase runoff rates and decrease runoff lag times, while a combination of these factors produces a compound effect. These impacts are driven by increased residual moisture content and decreased permeability due to surface sealing, and have previously been inferred from downstream observations of lahars but not identified at source. Water and sediment transport mechanisms differ based on surface grain size distribution: a fine-grained surface layer displayed airborne remobilisation, accretionary pellet formation, rapid surface sealing and infiltration-excess overland flow generation whilst a coarse surface layer demonstrated exclusively rainsplash-driven particle detachment throughout the rainfall simulations. This experimental protocol has the potential to quantitatively examine the effects of a variety of individual parameters in RTL initiation under controlled conditions

Probabilistic analysis of rain-triggered lahar initiation at Tungurahua volcano

Semi-continuous production of pyroclastic material by intermittent strombolian, vulcanian and sub-plinian eruptions at Volcán Tungurahua, Ecuador has created a persistent rain-triggered lahar hazard during the 1999-present eruptive episode. Lahars threaten the city of Baños, which lies approximately 8 km from the crater, as well as other villages and vital infrastructure situated in close proximity to the dense radial drainage network of the volcano. This study analyses the initiation of rain-triggered lahars and the influence of antecedent rainfall on this process in two northern instrumented drainages, La Pampa and the Vazcun. Analysis of lahar-triggering rainfall intensity and duration between March 2012 and June 2013 yields a power-law relationship, while Receiver Operating Characteristic (ROC) analysis indicates that peak rainfall intensity (10 minute, 30 minute and 60 minute) is the most effective single predictor of lahar occurrence. The probability of a lahar exceeding a pre-defined magnitude increases with peak rainfall intensity. Incorporation of antecedent rainfall (24 hour, 3 day, 5 day and 7 day) as a secondary variable significantly impacts lahar probabilities, particularly during moderate-high intensity rainfall events. The resultant two and three-dimensional lahar probability matrices are applied to rainfall data between 1st July and 31st December 2013 with the aim of predicting lahar occurrence. Composite lahar indicators comprised from the mean lahar probability estimates of individual matrices are shown to perform this task most effectively. ROC analysis indicates a probability >80% that these composite indicators will generate a higher estimated lahar probability for a randomly selected lahar event than a randomly selected non-lahar event. This method provides an average of 24 minutes of additional warning time compared with the current Acoustic Flow Monitors (AFMs) used for lahar detection, effectively doubling warning times for key downstream infrastructure in the two drainages. Ultimately, this method of lahar analysis could be used to construct real-time probabilistic rain-triggered lahar forecasts as an aid to current lahar hazard mitigation techniques at any location with a significant rain-triggered lahar hazard and a basic instrumental set-up