The Dilemma of Treating Delirium: the Conundrum of Drug Management.

OPINION STATEMENT: Delirium is a common medical complication in people living with cancer, particularly with more advanced disease. Delirium is associated with significant symptom burden which causes distress and impacts quality of life. As recommended by international guidelines, a high degree of suspicion is needed to ensure delirium is detected early. Attention to collateral history can provide clues to changes in cognition and attention. Non-pharmacological approaches that can be considered essential elements of care are effective in reducing the risk of delirium. Delirium screening using a validated measure is recommended as even expert clinicians can underdiagnose or miss delirium. The diagnostic assessment requires consideration of the cancer diagnosis and comorbidities, in the context of potential reversibility, goals of care, and patient preferences. The gold standard approach based on expert consensus is to institute management for delirium precipitants supported by non-pharmacological essential care, with the support of an interdisciplinary team. Medication management should be used sparingly and for a limited period of time wherever possible for severe perceptual disturbance or agitation which has not improved with non-pharmacological approaches. Clinicians should be familiar with the registered indication for medications and seek informed consent for off-label use. All interventions put in place to manage delirium need to consider net clinical benefit, including harms such as sedation and loss of capacity for meaningful interaction. Clear communication and explanation are needed regularly, with the person with delirium as far as possible and with surrogate decision makers. Delirium can herald a poor prognosis and this needs to be considered and be discussed as appropriate in shared decision-making. Recall after delirium has resolved is common, and opportunity to talk about this experience and the related distress should be offered during the period after recovery

A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes.

BACKGROUND:Delirium is a serious and distressing neurocognitive disorder of physiological aetiology that is common in advanced cancer. Understanding of delirium pathophysiology is largely hypothetical, with some evidence for involvement of inflammatory systems, neurotransmitter alterations and glucose metabolism. To date, there has been limited empirical consideration of the distinction between delirium pathophysiology and that of the underlying disease, for example, cancer where these mechanisms are also common in advanced cancer syndromes such as pain and fatigue. This systematic review explores biomarker overlap in delirium, specific advanced cancer-related syndromes and prediction of cancer prognosis. METHODS:A systematic review (PROSPERO CRD42017068662) was conducted, using MEDLINE, PubMed, Embase, CINAHL, CENTRAL and Web of Science, to identify body fluid biomarkers in delirium, cancer prognosis and advanced cancer-related syndromes of interest. Studies were excluded if they reported delirium tremens only; did not measure delirium using a validated tool; the sample had less than 75% of participants with advanced cancer; measured tissue, genetic or animal biomarkers, or were conducted post-mortem. Articles were screened for inclusion independently by two authors, and data extraction and an in-depth quality assessment conducted by one author, and checked by two others. RESULTS:The 151 included studies were conducted in diverse settings in 32 countries between 1985 and 2017, involving 28130 participants with a mean age of 69.3 years. Seventy-one studies investigated delirium biomarkers, and 80 studies investigated biomarkers of an advanced cancer-related syndrome or cancer prognosis. Overall, 41 biomarkers were studied in relation to both delirium and either an advanced cancer-related syndrome or prognosis; and of these, 24 biomarkers were positively associated with either delirium or advanced cancer syndromes/prognosis in at least one study. The quality assessment showed large inconsistency in reporting. CONCLUSION:There is considerable overlap in the biomarkers in delirium and advanced cancer-related syndromes. Improving the design of delirium biomarker studies and considering appropriate comparator/controls will help to better understanding the discrete pathophysiology of delirium in the context of co-existing illness

Beyond the frame: Use of augmented screenings as a visual methodology in critical event studies.

Disrupt is an ongoing project exploring methodologies appropriate to critical perspectives in event studies, suitable for researching activism, protest, and events of dissent. This paper considers the use of augmented film screenings, which combine cinematic presentation with non-film/live elements and panel-led discussions, as one of the approaches trialled as part of the project. Rooted in techniques based in photo and video elicitation, whilst incorporating aspects of the use of film to educate, stimulate and provoke radical debate, employed by Latin American activists since the 1960s, the augmented screening approach explored in this paper formulates an innovative approach in evental visual research methodology. Going further than photo and video elicitation, it combined film with live disruptive elements in the attendee experience to legitimise participant engagement with narratives that challenge the dominant hegemonic discourses in which we act and interact. In conclusion we consider some of the limitations and opportunities of evental research methods that use film as a key element within a framework anchored in a visual elicitation approach. Key words Photo-elicitation; Video-elicitation; Evental research; Protest; Critical event studies

Una xarxa de ciutats per un món de ciutadans : VIè Congrés Mundial Metropolis '99 : Barcelona, del 16 al 19 de març de 1999

Entre els dies 16 i 19 de març de 1999 es va celebrar a Barcelona el VIè Congrés Metropolis, organitzat per l'associació que porta el mateix nom, en el qual es van debatre temes referents a les polítiques de govern de les ciutats, tot incidint en quatre àmbits d'actuació: infraestructures aeroportuàries, qualitat mediambiental, desenvolupament econòmic i turisme cultural.Entre los días 16 y 19 de marzo se celebró en Barcelona el VI Congreso Metropolis, organizado por la asociación que lleva el mismo nombre, en el que se debatieron temas referentes a las políticas de gobierno de las ciudades, incidiendo en cuatro ámbitos de actuación: infraestructuras aeroportuarias, calidad medioambiental, desarrollo económico y turismo cultural.Entre le 16 et le 19 mars 1999 se déroula a Barcelona le VI Congrès Metropolis organisé par l'association du même nom. Les thèmes relatifs aux politiques du gouvernement urbain se sont débattus en mettant l'accent sur quatre secteurs: infrastructures aéroportuaires, qualité environnementale, développement economique et turisme culturel.The 6th edition of the Congress Metropolis was held in Barcelona between March 16th and March 19th 1999 and was organised by the Association with the same name. Several topics concerning governing policy of the cities were discussed, stressing four different working areas: airport infrastructures, environmental quality, economic development and cultural tourism

Are people in residential care entitled to receive rehabilitation services following hip fracture? Views of the public from a citizens' jury.

BACKGROUND:Access to rehabilitation services for people living in residential care facilities is frequently limited. A randomised trial of a hospital outreach hip fracture rehabilitation program in residential care facilities has demonstrated improvements in mobility at four weeks and quality of life at 12 months but was not considered cost-effective by standard health economic metrics. The current study aimed to explore the general public's views on issues involved in the allocation of rehabilitation resources for residents of care facilities. METHODS:A citizens' jury comprising 13 purposively sampled members of the general public, representative of the South Australian age, gender and household income profile. The jury considered the questions "Should there be an investment of physical rehabilitation services in residential care for older people following a hip fracture? If so, what is the best way of providing this service (considering funding, models of service delivery and equity)?" Deliberations were in the context of a state-wide health reform program. The jury was conducted over two days with an experienced independent facilitator, addressing questions developed by a steering group of research academics and clinicians. RESULTS:The mean age of the citizens' jury members was 43 (range 26 to 61). Eleven members voted for investment in outreach hospital rehabilitation services in residential aged care. All jurors agreed a number of strategies in addition to investment should be implemented, including health care planning and decision making, increased emphasis on hip fracture prevention, training of aged care staff in rehabilitation and routine provision of hospital discharge summaries to families. The jury further advocated for an increased focus on rehabilitation in residential care, potentially through accreditation criteria, increasing health literacy of residents and families, implementation of age friendly environment strategies and improving connections of care facilities with community, hospital and tertiary services. CONCLUSIONS:This citizens' jury representative of the general public recommends that regardless of dementia and frailty, people who live in residential care and are walking and fracture their hips should have access to hospital outreach rehabilitation and recovery services

Management of spontaneous pneumothorax in patients with COVID-19.

ObjectivesThe coronavirus disease 2019 (COVID-19) pneumonia may cause cystic features of lung parenchyma which can resolve or progress to larger blebs. Pneumothorax was more likely in patients with neutrophilia, severe lung injury and a prolonged clinical course. The timely diagnosis and management will reduce COVID-19-associated morbidity and mortality.MethodsWe present 11 cases of spontaneous pneumothorax managed with chest tube thoracostomy or high-dose oxygen therapy. Isolated spontaneous pneumothorax was detected in all cases.ResultsEight cases were male and 3 cases were female. There were bilateral ground-glass opacities or pulmonary infiltrates in the parenchyma of the 10 cases. We detected neutrophilia, lymphopaenia and increased C-reactive protein, Ferritin, lactate dehydrogenase, D-Dimer, interleukin-6 levels in almost all cases. Chest tube thoracostomy was sufficient to treat pneumothorax in our 9 of case. In 2 cases, pneumothorax healed with high-dose oxygen therapy. Favipiravir and antibiotic treatment were given to different 10 patients. In our institution, all patients with COVID-19 infection were placed on prophylactic or therapeutic anticoagulation, unless contraindicated. The treatments of patients diagnosed with secondary spontaneous pneumothorax during the pandemic period and those diagnosed with secondary spontaneous pneumothorax in the previous 3 years were compared with the durations of tube thoracostomy performed in both groups.ConclusionsThe increased number of cases of pneumothorax suggests that pneumothorax may be a complication of COVID-19 infection. During medical treatment of COVID-19, pneumothorax may be the only reason for hospitalization. Although tube thoracostomy is a sufficient treatment option in most cases, clinicians should be aware of the difficulties that may arise in diagnosis and treatment

Shielding features of concrete types containing sepiolite mineral: comprehensive study on experimental, XCOM and MCNPX results

Natural sepiolite mineral is a naturally occurring clay form belonging to a part of layered silicate. Because of its advantages such as low production cost, light-weight and convenient, it may be selected as an alternative shielding material to others. Radiation shielding performances of some concretes to sepiolite and B4C addictive have been researched reported in a wide energy region of 0.08–1.333 MeV using experimental data, MCNP and XCOM. The simulated data obtained by MCNPX are discussed and compared with the experimental results as well as with the XCOM results. The simulations match the experiments very well except for S3 sample. From the measurement, the maximum gamma-ray attenuation was detected in the concrete specimen with 10% sepiolite (S1) while the minimum attenuation of gamma-ray was noted in the concrete specimen with 30% sepiolite (S3). The addition of sepiolite mineral to concretes may be an alternative option that can be used in several radiation protection applications

Occasional papers, no. 13

While there are studies of the Border region, which give a picture of the economic, industrial, and physical features of the dominant centre of East London and of its Bantu population, no detailed study of the White population of the city had, prior to 1954, been published. So it was that in 1964 the present study was commenced as primarily a sociological analysis of the White population of East London. It was designed to deal with this gap in our knowledge of the region. The study includes a description of the historical development of the city, and some reference to its regional setting. The White population of the city is analysed in some detail.Digitised by Rhodes University Library on behalf of the Institute of Social and Economic Research (ISER

Quality of online self-management resources for adults living with primary brain cancer, and their carers: a systematic environmental scan

Background: A primary brain cancer diagnosis is a distressing, life changing event. It adversely affects the quality of life for the person living with brain cancer and their families (‘carers’). Timely access to evidence-based information is critical to enabling people living with brain cancer, and their carers, to self-manage the devastating impacts of this disease. Method: A systematic environmental scan of web-based resources. A depersonalised search for online English-language resources published from 2009 to December 2019 and designed for adults (> 25 years of age), living with primary brain cancer, was undertaken using the Google search engine. The online information was classified according to: 1) the step on the cancer care continuum; 2) self-management domains (PRISMS taxonomy); 3) basic information disclosure (Silberg criteria); 4) independent quality verification (HonCode); 5) reliability of disease and treatment information (DISCERN Sections 1 and 2); and readability (Flesch-Kincaid reading grade). Results: A total of 119 online resources were identified, most originating in England (n = 49); Australia (n = 27); or the USA (n = 27). The majority of resources related to active treatment (n = 76), without addressing recurrence (n = 3), survivorship (n = 1) or palliative care needs (n = 13). Few online resources directly provided self-management advice for adults living with brain cancer or their carers. Just over a fifth (n = 26, 22%) were underpinned by verifiable evidence. Only one quarter of organisations producing resources were HonCode certified (n = 9, 24%). The median resource reliability as measured by Section 1, DISCERN tool, was 56%. A median of 8.8 years of education was required to understand these online resources. Conclusions: More targeted online information is needed to provide people affected by brain cancer with practical self-management advice. Resources need to better address patient and carer needs related to: rehabilitation, managing behavioural changes, survivorship and living with uncertainty; recurrence; and transition to palliative care. Developing online resources that don’t require a high level of literacy and/or cognition are also required

Virtual models of care for people with palliative care needs living in their own home: A systematic meta-review and narrative synthesis.

Background: Access to palliative care in the community enables people to live in their preferred place of care, which is often home. Community palliative care services struggle to provide timely 24-h services to patients and family. This has resulted in calls for ‘accessible and flexible’ models of care that are ‘responsive’ to peoples’ changing palliative care needs. Digital health technologies provide opportunities to meet these requirements 24-h a day. Aim: To identify digital health technologies that have been evaluated for supporting timely assessment and management of people living at home with palliative care needs and/or their carer(s), and the evidence-base for each. Design: A systematic review of systematic reviews (‘meta-review’). Systematic reviews evaluating evidence for virtual models of palliative or end-of-life care using one or more digital health technologies were included. Systematic reviews were evaluated using the Risk of Bias Tool for Systematic Reviews. A narrative approach was used to synthesise results. Data sources:Medline, Embase, Web of Science, CINAHL and Cochrane Database of systematic reviews were searched for English-language reviews published between 2015 and 2020. Results: The search yielded 2266 articles, of which 12 systematic reviews met criteria. Sixteen reviews were included in total, after four reviews were found via handsearching. Other than scheduled telehealth, video-conferencing, or after-hours telephone support, little evidence was found for digital health technologies used to deliver virtual models of palliative care. Conclusions: There are opportunities to test new models of virtual care, beyond telehealth and/or video conferencing, such as 24-h command centres, and rapid response teams