Evidence-based strategies to reduce the incidence of postoperative delirium: a narrative review.

Delirium is one of the most commonly occurring postoperative complications in older adults. It occurs due to the vulnerability of cerebral functioning to pathophysiological stressors. Identification of those at increased risk of developing delirium early in the surgical pathway provides an opportunity for modification of predisposing and precipitating risk factors and effective shared decision-making. No single delirium prediction tool is used widely in surgical settings. Multi-component interventions to prevent delirium involve structured risk factor modification supported by geriatrician input; these are clinically efficacious and cost effective. Barriers to the widespread implementation of such complex interventions exist, resulting in an 'implementation gap'. There is a lack of evidence for pharmacological prophylaxis for the prevention of delirium. Current evidence suggests that avoidance of peri-operative benzodiazepines, careful titration of anaesthetic depth guided by processed electroencephalogram monitoring and treatment of pain are the most effective strategies to minimise the risk of delirium. Addressing postoperative delirium requires a collaborative, whole pathway approach, beginning with the early identification of those patients who are at risk. The research agenda should continue to examine the potential for pharmacological prophylaxis to prevent delirium while also addressing how successful models of delirium prevention can be translated from one setting to another, underpinned by implementation science methodology.

A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care.

OBJECTIVES: A comorbid diagnosis of cancer and dementia (cancer-dementia) may have unique implications for patient cancer-related experience. The objectives were to estimate prevalence of cancer-dementia and related experiences of people with dementia, their carers and cancer clinicians including cancer screening, diagnosis, treatment and palliative care. METHOD: Databases were searched (CINAHL, Psychinfo, Medline, Embase, BNI) using key terms such as dementia, cancer and experience. Inclusion criteria were as follows: (a) English language, (b) published any time until early 2016, (c) diagnosis of cancer-dementia and (d) original articles that assessed prevalence and/or cancer-related experiences including screening, cancer treatment and survival. Due to variations in study design and outcomes, study data were synthesised narratively. RESULTS: Forty-seven studies were included in the review with a mix of quantitative (n = 44) and qualitative (n = 3) methodologies. Thirty-four studies reported varied cancer-dementia prevalence rates (range 0.2%-45.6%); the others reported reduced likelihood of receiving: cancer screening, cancer staging information, cancer treatment with curative intent and pain management, compared to those with cancer only. The findings indicate poorer cancer-related clinical outcomes including late diagnosis and higher mortality rates in those with cancer-dementia despite greater health service use. CONCLUSIONS: There is a dearth of good-quality evidence investigating the cancer-dementia prevalence and its implications for successful cancer treatment. Findings suggest that dementia is associated with poorer cancer outcomes although the reasons for this are not yet clear. Further research is needed to better understand the impact of cancer-dementia and enable patients, carers and clinicians to make informed cancer-related decisions.

Structural and functional characterization of TesB from Yersinia pestis reveals a unique octameric arrangement of hotdog domains.

Acyl-CoA thioesterases catalyse the hydrolysis of the thioester bonds present within a wide range of acyl-CoA substrates, releasing free CoASH and the corresponding fatty-acyl conjugate. The TesB-type thioesterases are members of the TE4 thioesterase family, one of 25 thioesterase enzyme families characterized to date, and contain two fused hotdog domains in both prokaryote and eukaryote homologues. Only two structures have been elucidated within this enzyme family, and much of the current understanding of the TesB thioesterases has been based on the Escherichia coli structure. Yersinia pestis, a highly virulent bacterium, encodes only one TesB-type thioesterase in its genome; here, the structural and functional characterization of this enzyme are reported, revealing unique elements both within the protomer and quaternary arrangements of the hotdog domains which have not been reported previously in any thioesterase family. The quaternary structure, confirmed using a range of structural and biophysical techniques including crystallography, small-angle X-ray scattering, analytical ultracentrifugation and size-exclusion chromatography, exhibits a unique octameric arrangement of hotdog domains. Interestingly, the same biological unit appears to be present in both TesB structures solved to date, and is likely to be a conserved and distinguishing feature of TesB-type thioesterases. Analysis of the Y. pestis TesB thioesterase activity revealed a strong preference for octanoyl-CoA and this is supported by structural analysis of the active site. Overall, the results provide novel insights into the structure of TesB thioesterases which are likely to be conserved and distinguishing features of the TE4 thioesterase family.

Developing a healthy living intervention for people with early psychosis using the Medical Research Council's guidelines on complex interventions: phase 1 of the HELPER - InterACT programme.

BACKGROUND: Young people with early psychosis often gain a significant amount of weight after the initiation of anti-psychotic treatment. Despite the current policy guidance to develop and evaluate 'healthy living' interventions for people with psychosis there remains a paucity of research. Our aim was to develop an acceptable, feasible, culturally sensitive and potentially effective 'healthy living' intervention, specifically for young people with early psychosis. METHODS: Using the Medical Research Council guidelines for developing and evaluating complex interventions we conducted a number of studies to devise a 'healthy living' intervention. We used a 'top down' (published evidence), bottom up (stakeholder perspectives) approach, which included updating a systematic review, identifying a theoretical basis for the intervention, exploring the perspectives of service users and health professionals, and identifying key cultural issues. The results of these studies were synthesised to determine the content and delivery of the intervention. RESULTS: The intervention developed comprised eight individual sessions to be delivered by a support time recovery worker over a 12 month period with emphasis on individualised action plans to facilitate participatory exercise and changes in diet. To optimise engagement, choice and self management a booklet and website were developed to provide participants with educational advice, healthy eating recipes and other materials. CONCLUSION: Using the Medical Research Council guidelines we have developed a potentially effective, feasible and acceptable 'healthy living' intervention for people with psychosis using early intervention services in the UK.

Do 'do not attends' at a genitourinary medicine service matter?

Patients who do not attend (DNA) clinic appointments are wasteful of resources and may also pose a potential public health risk through the onward transmission of untreated sexually transmitted infections (STIs). This service evaluation was performed to assess the demographics of DNAs, patient reasons for non-attendance and follows up data to determine the health outcomes of non-attendance. The genitourinary (GU) medicine clinic DNA rate between October 2008 and March 2009 was 6% (383/6961). Of the 383 patients who DNA'd their appointment successful telephone contact was made in 182 (48%) of them. Of these 40% of patients reported that they had forgotten they held an appointment; no patients reported that clinic opening hours prevented their attendance. Telephone contact increased GU medicine clinic attendance by 9% (35/383), but led to a greater number of subsequent DNAs; 43/75 (63%) of patients who accepted a further appointment DNA'd that appointment. Sending a SMS text message to patients who DNA notifying them of the time of walk-in services might be the most effective way of recapturing these patients without compromising future clinic appointment slots.

Forearm bone geometry and mineral content in UK women of European and South-Asian origin.

Ethnic variation in areal bone mineral density (BMD) has been well documented. Such variation may, however, reflects differences in bone geometry rather than volumetric BMD (vBMD). The aim of the study was to compare bone geometry, mineral content (BMC) and vBMD in two ethnic groups, and study the influence of body size, physical activity, reproductive variables, 25 hydroxy-vitamin D (25(OH)D) and parathormone (PTH) status on any observed differences. The data were from a population-based, cross-sectional survey of peak bone mass in South Asian and European women, the population consisted 230 pre-menopausal South Asian (n=118, mean age 28.6+/-4.6 years) and European (n=112, mean age 30+/-4.3 years) women of UK origin. Women who participated completed an interviewer assisted questionnaire, had blood taken for assessment of 25(OH)D and PTH and had measurements of their distal (4%) and diaphyseal (50%) radius geometry, BMC and vBMD using peripheral quantitative computed tomography. At the 50% radius, South Asians had lower vBMD (p<0.001), BMC (p<0.001), cortical area (p<0.001), cortical thickness (p<0.001), cross-sectional area (p=0.04) and increased medullary area (p<0.04). Cross-sectional muscle area and stress strain index, however, were not different. Adjustment for age, height and weight attenuated, the difference in cross-section area but did not account for any of the other observed differences. Further adjustment for reproductive variables a physical activity index, 25(OH)D and PTH, attenuated ethnic differences in cortical BMC, area and thickness which became non-significant; however, ethnic differences in cortical vBMD and medullary area persisted. At the 4% site, after adjusting for age, height and weight, there was no difference in total area, total or trabecular vBMD between ethnic groups. After further adjustment for physical activity, reproductive variables, 25(OH)D and PTH, trabecular vBMD was higher in the South Asians. In conclusion, there are differences in bone geometry, BMC and vBMD at the radial diaphysis between UK South Asians and Europeans which are not explained by differences in body size. Polar stress-strain index was similar, however, suggesting no important differences in bone strength.

Occurrence and risk factors for falls in rheumatoid arthritis.

OBJECTIVES: To determine the one year period prevalence of falls by age and sex in patients with rheumatoid arthritis and the influence of concurrent medical treatment and disability on the occurrence of falls in this group. METHODS: A consecutive series of rheumatoid patients aged 35 years and over, attending hospital outpatient clinics at Hope hospital, Salford, were asked to complete an interview assisted questionnaire which asked about the occurrence and number of falls in the previous 12 months. SUBJECTS: who took part were asked about current treatment with antihypertensive agents, diuretics, sedatives or hypnotics, antidepressants, and a history of previous hip/knee surgery. They also completed the health assessment questionnaire (HAQ). Logistic regression was used to determine the association between these variables and falls in the previous 12 months. RESULTS: 253 men and women, mean age 62 years, were studied, and 84 (33%) reported falling in the previous year (36% of women and 26% of men). Of these, 52% had fallen on more than one occasion. There was no important increase in the frequency of falls with age. After adjusting for age and sex, those who had fallen in the previous year were more likely to report taking antidepressant treatment (odds ratio (OR) = 2.09) and to have impairment in both walking (OR = 1.37) and rising (OR = 1.41). The HAQ score was higher in those who reported a fall than those who did not, though the difference was not statistically significant. CONCLUSIONS: In this hospital based survey, one in three patients with rheumatoid arthritis reported falling in the previous 12 months. Falls were associated with self reported impairment in lower limb function.