Evaluating outcomes from an integrated health service for older patients

Background: Hospital-associated disability is the loss of the ability to complete one activity of daily living (ADL), with this decline occurring between the onset of acute illness and discharge from the hospital. Approximately 30% of patients who are >70 years old and admitted to hospitals are discharged with an ADL disability. Comprehensive geriatric assessment (CGA) models use a multidimensional, interdisciplinary process of diagnosis and treatment with the goal of improving outcomes and decreasing lengths of stay. Methods: A retrospective clinical audit of Ipswich Hospital’s medical records included patients for random selection who were >75 years of age and had an acute admission to the Older Person Evaluation Review and Assessment (OPERA) or general medicine (GM) service from July 2012 to December 2012. Data were collected for the entire admission period on length of stay, comorbidities, allied health visits, functional ability, and delirium and dementia at admission. Results: Of the 267 patients evaluated, 133 were admitted to the OPERA service, and 134 were admitted to the GM service. Patients admitted to the OPERA service were significantly more ill than patients admitted to the GM service as measured by the Charlson Comorbidity Index scores (6.53 - 1.83 vs 6.02 - 1.96, respectively, P¼0.02), Katz Index of Independence in ADL scores (3.77 - 2.22 vs 4.72 - 2.00, respectively,

Enhancing clinical care and investigating a novel therapeutic approach for multiple paragangliomas

Paragangliomas (PGLs) are rare tumours of the autonomic nervous system that cause high morbidity and mortality. Diagnosis and management can be challenging and no consensus on pre-operative management exists. PGLs arise in sporadic and familial forms and have the potential for malignant transformation. Despite significant advances in identification of genetic causes there is still a lack of understanding in the pathogenesis of the different clinical phenotypes. Surgical resection is the only cure, but once metastases have occurred treatment options are limited. This thesis aims to address some of these issues with the overall objective of improving clinical care for affected patients and their relatives. The first part of this research focuses on pre-operative management. Using home blood pressure monitoring and personalised titration of medications, the presented data show improved compliance with alpha-blockade medication. Duration of treatment appears to be an important factor in intra- and post-operative haemodynamic instability. Analysis of bioimpedance and serum inflammatory markers demonstrated that medical therapy is potentially able to reverse the inflammatory and catabolic effects of catecholamine excess. Part two focuses on mutations within the Succinate Dehydrogenase (SDH) genes. Mutations in any of these can cause disruption in SDH enzymatic function, but penetrance, clinical presentation and tumour aggressiveness differ between subunits. A model for surveillance monitoring is proposed based on collated data. The final part investigates the immune cell composition of the tumour microenvironment (TME). Emerging evidence suggests that the TME correlates with clinical outcome, however, little is known about the TME of PGLs. Immune cells in the TME were assessed using immunohistochemistry. There was a higher proportion of immune cells in tumour tissue compared to non-pathological medulla, with a predominance of macrophages. Differences in the TME were observed between aggressive and benign tumours. These observations could potentially be exploited as an aid in predicting tumour behaviour

Self-disclosure within the sport-psychologist athlete relationship

This article explores the use of self-disclosure within the sport psychologist-athlete relationship. A summary of prior research relevant to concept definition, contextual factors, and typologies of self-disclosure is provided. The conscious use of self-disclosure as an effective consultancy skill, alongside both the organic and facilitative integration of self-disclosure is discussed. We then position self-disclosure within the dynamics and boundaries of a unique practitioner context, that of the sport psychologist-athlete relationship, using Katz and Hemmings’ (2009) professional relationship framework. This article proposes that future research into self-disclosure explores its integration within published models of best practice for consulting

The cost of reproduction in callosobruchus maculatus.

The bruchid beetle Callosobruchus maculatus does not feed as an adult. The resources such as energy or nutrients available to it are therefore fixed at emergence. Allocation of resources to processes contributing to one trait must therefore reduce those available for allocation to others and trade-offs between these traits are expected. The present study investigates the trade-off between current and future reproduction, the cost of reproduction, in both females and males of this species taking an explicitly phenotypic approach. The trade-off between adult longevity and lifetime fecundity in females is demonstrated using experimental manipulations of fecundity. It is shown that reduced adult longevity reflects reduced future reproduction and that this trade-off is therefore the cost of reproduction. The inadequacy of phenotypic correlations in demonstrating this trade-off is shown. The allocations of dry weight, water, lipid and energy by females to reproductive and non-reproductive processes are measured. For each resource, the predicted slope of the trade-off between adult longevity and lifetime fecundity is calculated based on that resource being limiting. From a comparison between these predicted slopes and the slope measured using experimental manipulation, it is concluded that none of these resources can be rejected as the limiting resource and that they all may contribute to the trade-off. Males make a non-trivial investment in ejaculate. This investment reduces a male's future reproductive success. To some extent these costs are short-term; the male soon regains his fertility. However, there are also long-term costs due to reduced longevity. The fitness consequences of remating to females are investigated. Fecundity is increased following remating but it is impossible to distinguish between the nutritional and manipulative roles of the ejaculate. Finally, the costs of reproduction are summarised and their generality and implications discussed

Multianalyte Association Between Intestinal Alkaline Phosphatase and Pediatric Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a generalized inflammatory gastrointestinal (GI) disease that includes Ulcerative Colitis (UC) and Crohn’s disease (CD). Consideration of diagnostic choices outside of endoscopy are urgent, and especially so for the pediatric population. A growing number of diagnosed IBD cases with rates up to 25% of all IBD occurrences are pediatric cases. Current available fecal markers have yet to satisfy desired characteristics. For example, thus far, they can achieve moderate specificity but low sensitivity, but they cannot reliably stratify patients into a quiescent, mild, moderately active, or severe disease states. Intestinal alkaline phosphatase (iAP), an enzyme shed in the gut to maintain microbial homeostasis, has been shown to be a promising fecal marker for diagnosing gastrointestinal bowel disease in preterm infants. This study evaluated iAP as a marker for disease staging in treatment-naïve pediatric IBD patients, who were free from complications for 90 days after their diagnosis. We performed biochemical analysis on stool samples from 199 enrollees in the national pediatric RISK stratification study, the largest, new-onset prospective study involving 28 clinics in the US and Canada, and from 16 non-IBD patients enrolled at Children’s Hospital. Mean and standard deviation of total protein content, iAP abundance, and iAP enzyme activity was determined. Overall, samples from patients with UC had significantly reduced iAP activity. There was an overall significant increase in the abundance of iAP in these patients and the amount correlated directly with more severe disease. In CD patients, iAP activity was reduced and a modest increase in iAP abundance was observed. Increased abundance of iAP in pediatric stool samples was highly correlative with severe UC. Reduced enzymatic activity in these patients suggest that iAP is dysfunctional and cannot maintain gut homoeostasis and subsequently leads to severe disease. From this study, we conclude that aberrant human-microbiota crosstalk is correlated with severity of UC and suggests an iAP biomarker may be a promising method to monitor IBD and disease severity

Hepatitis B assessment without hepatitis B virus DNA quantification: a prospective cohort study in Uganda

BACKGROUND: Chronic hepatitis B infection affects 240 million people, with the highest prevalence in Africa and Asia, and results in 700 000 deaths annually. Access to diagnostics, particularly for hepatitis B virus viral load quantification (HBV DNA), is a major barrier to treatment. We aimed to test World Health Organization guidelines for hepatitis B management in resource-limited settings. METHODS: We compared treatment allocation with and without the use of HBV DNA in a cohort in Uganda. Hepatitis B surface antigen test-positive, human immunodeficiency virus-negative, treatment-naïve adults were recruited prospectively. Following liver ultrasound and routine haematological and biochemical tests, preliminary allocations into treatment and observation groups were made. HBV DNA was performed for each participant and final treatment decisions were made and compared with preliminary allocations. RESULTS: Full assessment was completed for 100 participants; treatment was indicated in 20. Assessment without HBV DNA identified patients for treatment with a positive predictive value of 88.2% and a negative predictive value of 94% compared with assessment using HBV DNA. CONCLSUIONS: Where HBV DNA is unavailable, patients with hepatitis B can be assessed by liver ultrasound and routine laboratory tests. These findings will enable physicians in resource-limited settings to initiate treatment more readily and inform policy with regards to viral hepatitis elimination