A quality improvement project addressing the underreporting of delirium in hip fracture patients.

INTRODUCTION: After discovering a low incidence of delirium for hip fracture patients at our institution, we evaluated if this was due to underreporting and, if so, where process errors occurred. METHODS: Hip fracture patients aged ≥60 with a diagnosis of delirium were identified. Chart-Based Delirium Identification Instrument (CHART-DEL) identified missed diagnoses of delirium. Process maps were created based off staff interviews and observations. RESULTS: The incidence of delirium was 15.3% (N = 176). Within a random sample (n = 98), 15 patients (15.5%) were diagnosed, while 20 (24.7%) went undiagnosed despite evidence of delirium. Including missed diagnoses, delirium prevalence was higher in the sample compared to all patients (35.7% vs 15.3%, p < 0.001). Most missed diagnoses were due to failure in identifying delirium (60%) or failure in documenting/coding diagnosis (20%). The prevalence of baseline cognitive impairment was higher in undiagnosed delirium patients versus correctly diagnosed patients (80% vs 20%, p = 0.001). CONCLUSIONS: Our institution significantly underreports delirium among hip fracture patients mainly due to; (1) failure to identify delirium by the clinical staff, and (2) failure to document/code diagnosis despite correct identification. Baseline cognitive impairment can render delirium diagnosis challenging. These serve as targets for quality improvement and hip fracture care enhancement.

Six Principles for Embracing Gender and Sexual Diversity in Postsecondary Biology Classrooms.

Sexual and gender minorities face considerable inequities in society, including in science. In biology, course content provides opportunities to challenge harmful preconceptions about what is "natural" while avoiding the notion that anything found in nature is inherently good (the appeal-to-nature fallacy). We provide six principles for instructors to teach sex- and gender-related topics in postsecondary biology in a more inclusive and accurate manner: highlighting biological diversity early, presenting the social and historical context of science, using inclusive language, teaching the iterative process of science, presenting students with a diversity of role models, and developing a classroom culture of respect and inclusion. To illustrate these six principles, we review the many definitions of sex and demonstrate applying the principles to three example topics: sexual reproduction, sex determination or differentiation, and sexual selection. These principles provide a tangible starting place to create more scientifically accurate, engaging, and inclusive classrooms.

Pharmacological Management of Bipolar Disorder in Pregnancy.

Bipolar disorder is associated with high morbidity and mortality. The management of bipolar disorder includes a broad approach involving psychoeducation, psychological therapies and psychotropic medication. The management of bipolar disorder in pregnancy is challenging; there is an increase in the rate of relapse of bipolar disorder in the perinatal period and treatment decisions are complex as clinicians are required to weigh up the risks of untreated illness versus unwanted treatment effects on both the mother and the developing fetus. Whilst depressive relapses are more common, women are also at an increased risk of postpartum psychosis, which is a psychiatric emergency that almost always requires inpatient treatment. This paper discusses the limited evidence base regarding the safety of psychotropic medication in the perinatal period, including challenges in perinatal mental health research and the lack of robust evidence. The general principles of prescribing in pregnancy, the importance of preconception counselling, and the risks and benefits associated with antipsychotics, mood stabilisers and antidepressants are addressed.

Psychometric properties of the Body Checking Questionnaire in college women.

While the Body Checking Questionnaire (BCQ; Reas et al., 2002) is the most commonly-used measure of body checking behaviors, findings on the factor structure in nonclinical samples are mixed. This study investigated the factor structure and psychometric properties of the BCQ among nonclinical college women. In Study 1 (n=326), an exploratory factor analysis indicated factors corresponding to (a) behavioral and (b) visual checking. In Study 2 (n=1013), a confirmatory factor analysis revealed adequate fit for these factors, better than the original or total score solutions. Scales based upon the two factors demonstrated good internal consistency, convergent validity with measures of eating pathology, and sensitivity for detecting at-risk eating pathology. Results suggest an alternate two-factor solution that differs from the original three-factor solution.

Higher or lower? The functional anatomy of perceived allocentric social hierarchies.

The perception and judgement of social hierarchies forms an integral part of social cognition. Hierarchical judgements can be either self-referential or allocentric (pertaining to two or more external agents). In psychiatric conditions such as dissocial personality disorder and schizophrenia, the impact of hierarchies may be problematic. We sought to elucidate the brain regions involved in judging allocentric social hierarchies. Twenty-two healthy male subjects underwent three fMRI scans. During scanning, subjects answered questions concerning visually-presented target pairs of human individual's relative superiority within a specific social hierarchy or their perceived degree of social alliance (i.e., whether they were "friends or enemies"). Subjects also made judgements relating to target pairs' age, gender and fame to control for confounding factors and performed a baseline numerical task. Response times increased in line with hypothesized ascending executive load. Both social hierarchy and social alliance judgements activated left ventrolateral prefrontal cortex (VLPFC), left dorsal inferior frontal gyrus (IFG) and bilateral fusiform gyri. In addition, social alliance judgements activated right dorsal IFG and medial prefrontal cortex. When compared directly with social alliance, social hierarchy judgements activated left orbitofrontal cortex. Detecting the presence of social hierarchies and judging other's relative standing within them implicates the cognitive executive, in particular the VLPFC. Our finding informs accounts of 'normal' social cognition but our method also provides a means of probing the dissocial brain in personality disorder and schizophrenia where executive function may be dysfunctional.

Calcium supplementation increases stature and bone mineral mass of 16- to 18-year-old boys.

The effect of calcium carbonate supplementation on bone growth and mineral accretion was studied in 143 boys aged 16-18 yr, randomized to 1000 mg Ca/d or a matching placebo for 13 months. Anthropometry and dual-energy x-ray absorptiometry of the whole body, lumbar spine, hip, and forearm were performed before, during, and after the intervention. The intervention resulted in greater bone mineral content (BMC) of the whole body (+1.3%, P = 0.02), lumbar spine (+2.5%, P = 0.004), and hip (total +2.3%, P = 0.01; neck +2.4%, P = 0.02; intertrochanter +2.7%, P = 0.01). This was associated with greater height (+0.4%, P = 0.0004, equivalent to 7 mm), lean mass (+1.3%, P = 0.02), and lumbar spine bone area (+1.5%, P = 0.003). The increases in BMC diminished after size adjustment, suggesting that the intervention effect was mediated through an effect on growth. The BMC response at the intertrochanter was greater in subjects with high physical activity (+4.4%, P = 0.05). There were no other significant interactions with physical activity, plasma testosterone, calcium intake, or tablet compliance. We conclude that calcium carbonate supplementation of adolescent boys increased skeletal growth, resulting in greater stature and bone mineral acquisition. Follow-up studies will determine whether this reflects a change in the tempo of growth or an effect on skeletal size that persists into adulthood.

Effect of a calcium and exercise intervention on the bone mineral status of 16-18-y-old adolescent girls.

BACKGROUND: Osteoporosis may be prevented or delayed by maximizing peak bone mass through diet modification and physical activity during adolescence. OBJECTIVE: We studied whether increases in calcium intake and physical activity effectively increase the bone mineral status of adolescent girls aged 16-18 y. DESIGN: We conducted a 15.5-mo study of calcium supplementation (1000 mg Ca/d as carbonate) in 144 adolescent girls aged 17.3 +/- 0.3 y ( +/- SD). The subjects were randomly allocated to an exercise (three 45-min exercise-to-music classes/wk during term time) or nonexercise group. Dual-energy X-ray absorptiometry of the whole body, spine, forearm, and hip was performed before and after intervention. RESULTS: The mean (+/- SD) percentage of subjects compliant with supplement taking was 70 +/- 27% and with exercise class attendance was 36 +/- 25%. Baseline calcium intake was 938 +/- 411 mg/d. Calcium supplementation significantly increased size-adjusted bone mineral content. The effect was stronger in subjects with good compliance (percentage difference +/- SE): whole body, 0.8 +/- 0.3% (P < or = 0.01); lumbar spine, 1.9 +/- 0.5% (P < or = 0.001); ultradistal radius, 1.3 +/- 0.6% (P < or = 0.05); total hip, 2.7 +/- 0.6% (P < or = 0.001); femoral neck, 2.2 +/- 0.7% (P < or = 0.001); trochanter, 4.8 +/- 0.9% (P < or = 0.001). Attendance at > 50% of the exercise sessions was significant at the total hip (1.4 +/- 0.7%; P < or = 0.05) and trochanter (2.6 +/- 1.2%; P < or = 0.05). CONCLUSIONS: Calcium supplementation and exercise enhanced bone mineral status in adolescent girls. Whether this is a lasting benefit, leading to the optimization of peak bone mass and a reduction in fracture risk, needs to be determined.