Using ambulance service PCRs to understand 999 call-outs to older people with dementia

This document is the Accepted Manuscript version of a Published Work that appeared in final form in Journal of Paramedic Practice, copyright © 2016 MA Healthcare, after peer review and technical editing by the publisher. To access the final edited and published work see: http://www.magonlinelibrary.com/doi/10.12968/jpar.2016.8.5.246Objectives: To use local ambulance service patient care records (PCRs) at an aggregate level to study the use of emergency medical services (EMS) by older people with dementia in two English counties. To understand how and where in the PCR dementia is recorded. To measure the proportion of patients aged 75 and over who had an emergency (999) ambulance response who have dementia recorded in the PCR. To carry out a descriptive analysis of any associations with age, gender, reason for the call, time of call, residential status or call outcome. Methods: Four days of PCRs from two counties (UK) for patients aged 75 and over were reviewed and non-patient-identifiable data extracted. Data for the total number of call-outs for those days were obtained from the computer-aided dispatch (CAD) system. Results: In 4 days' records for Cambridgeshire and Hertfordshire (2 304 records), over one third of call-outs (830) were to patients aged 75 and over. Data were obtained from 358 paper records. Dementia was recorded on 14.5% of records and another 7.0% recorded details suggesting dementia or cognitive impairment. Around 15% of call-outs to ≥75-year-olds were to care homes. Ambulance crews attended higher proportions of ‘older old’ people than the local population percentages of 85 to 89-year-olds and ≥90-year-olds. The most common reason (27.5%) for a call-out was a fall. Conclusions: This is the first paper to look in detail at the numbers of older people with dementia seen by emergency ambulance crews as documented in PCRs. It gives a benchmark for others looking at ambulance service data and highlights possibilities and pitfalls of using ambulance service PCR data.Peer reviewedFinal Accepted Versio

Regulating Scotland's social landlords: localised resistance to technologies of performance management

Influenced by Foucault's later work on governmentality, this paper explores the regulation of social landlords as a 'technology of performance' concerned with governing the conduct of dispersed welfare agencies and the professionals within them. This is a mode of power that is both voluntary and coercive; it seeks to realise its ambitions not through direct acts of intervention, but by promoting the responsible self-governance of autonomous subjects. Through an analysis of the regulatory framework for social landlords in Scotland, this paper highlights the creation of a performance culture that seeks to mobilise housing organisations to reconcile their local management systems and service provision to external standards, whilst simultaneously wielding punitive interventions for non-compliance. However, housing professionals are not passive in all of this, and indeed, actively challenged and resisted these top-down attempts to govern them at arm's-length

Defective Molecular Timer in the Absence of Nucleotides Leads to Inefficient Caspase Activation

In the intrinsic death pathway, cytochrome C (CC) released from mitochondria to the cytosol triggers Apaf-1 apoptosome formation and subsequent caspase activation. This process can be recapitulated using recombinant Apaf-1 and CC in the presence of nucleotides ATP or dATP [(d)ATP] or using fresh cytosol and CC without the need of exogenous nucleotides. Surprisingly, we found that stored cytosols failed to support CC-initiated caspase activation. Storage of cytosols at different temperatures led to the loss of all (deoxy)nucleotides including (d)ATP. Addition of (d)ATP to such stored cytosols partially restored CC-initiated caspase activation. Nevertheless, CC could not induce complete caspase-9/3 activation in stored cytosols, even with the addition of (d)ATP, despite robust Apaf-1 oligomerization. The Apaf-1 apoptosome, which functions as a proteolytic-based molecular timer appeared to be defective as auto-processing of recruited procaspase-9 was inhibited. Far Western analysis revealed that procaspase-9 directly interacted with Apaf-1 and this interaction was reduced in the presence of physiological levels of ATP. Co-incubation of recombinant Apaf-1 and procaspase-9 prior to CC and ATP addition inhibited CC-induced caspase activity. These findings suggest that in the absence of nucleotide such as ATP, direct association of procaspase-9 with Apaf-1 leads to defective molecular timer, and thus, inhibits apoptosome-mediated caspase activation. Altogether, our results provide novel insight on nucleotide regulation of apoptosome

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

The Governance of Corporate Responses to Climate Change: An International Comparison

In response to pressures from governments, investors, non-governmental organisations and other stakeholders, many large corporations have adopted a variety of carbon and energy management practices, taken action to reduce their emissions and set targets to reduce their greenhouse gas emissions. Using the case of international retailers, this article examines whether, and under what conditions, non-state actors might be capable of assuming the governance roles that have historically been played by national governments. This article concludes that external governance pressures can, if they are aligned, robust and of sufficient duration, have a significant influence on internal governance processes and on corporate strategies and actions. However, the specific actions that are taken by companies – in particular those that require significant capital investments – are constrained by the ‘business case’. That is, companies will generally only invest capital in situations when there is a clear financial case (i.e. where the benefits outweigh the costs, when the rate of return meets or exceeds company targets) for action. That is, the extent to which external governance pressures can force companies to take action, in particular challenging or transformative actions that go beyond the boundaries of the business case, is not at all clear. This is particularly the case if the business case weakens, or if the opportunities for incremental change are exhausted. In that context, the power of non-state actors to force them to consider radical changes in their business processes and their use of energy therefore seems to be very limited

DNA Barcode Detects High Genetic Structure within Neotropical Bird Species

BACKGROUND: Towards lower latitudes the number of recognized species is not only higher, but also phylogeographic subdivision within species is more pronounced. Moreover, new genetically isolated populations are often described in recent phylogenies of Neotropical birds suggesting that the number of species in the region is underestimated. Previous COI barcoding of Argentinean bird species showed more complex patterns of regional divergence in the Neotropical than in the North American avifauna. METHODS AND FINDINGS: Here we analyzed 1,431 samples from 561 different species to extend the Neotropical bird barcode survey to lower latitudes, and detected even higher geographic structure within species than reported previously. About 93% (520) of the species were identified correctly from their DNA barcodes. The remaining 41 species were not monophyletic in their COI sequences because they shared barcode sequences with closely related species (N = 21) or contained very divergent clusters suggestive of putative new species embedded within the gene tree (N = 20). Deep intraspecific divergences overlapping with among-species differences were detected in 48 species, often with samples from large geographic areas and several including multiple subspecies. This strong population genetic structure often coincided with breaks between different ecoregions or areas of endemism. CONCLUSIONS: The taxonomic uncertainty associated with the high incidence of non-monophyletic species and discovery of putative species obscures studies of historical patterns of species diversification in the Neotropical region. We showed that COI barcodes are a valuable tool to indicate which taxa would benefit from more extensive taxonomic revisions with multilocus approaches. Moreover, our results support hypotheses that the megadiversity of birds in the region is associated with multiple geographic processes starting well before the Quaternary and extending to more recent geological periods

Discourse and religion in educational practice

Despite the existence of long-held binaries between secular and sacred, private and public spaces, school and religious literacies in many contemporary societies, the significance of religion and its relationship to education and society more broadly has become increasingly topical. Yet, it is only recently that the investigation of the nexus of discourse and religion in educational practice has started to receive some scholarly attention. In this chapter, religion is understood as a cultural practice, historically situated and embedded in specific local and global contexts. This view of religion stresses the social alongside the subjective or experiential dimensions. It explores how through active participation and apprenticeship in culturally appropriate practices and behaviors often mediated intergenerationally and the mobilisation of linguistic and other semiotic resources but also affective, social and material resources, membership in religious communities is constructed and affirmed. The chapter reviews research strands that have explored different aspects of discourse and religion in educational practice as a growing interdisciplinary field. Research strands have examined the place and purpose of religion in general and evangelical Christianity in particular in English Language Teaching (ELT) programmes and the interplay of religion and teaching and learning in a wide range of religious and increasingly secular educational contexts. They provide useful insights for scholars of discourse studies to issues of identity, socialisation, pedagogy and language policy

Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial

Background: Antiplatelet therapy reduces the risk of major vascular events for people with occlusive vascular disease, although it might increase the risk of intracranial haemorrhage. Patients surviving the commonest subtype of intracranial haemorrhage, intracerebral haemorrhage, are at risk of both haemorrhagic and occlusive vascular events, but whether antiplatelet therapy can be used safely is unclear. We aimed to estimate the relative and absolute effects of antiplatelet therapy on recurrent intracerebral haemorrhage and whether this risk might exceed any reduction of occlusive vascular events. Methods: The REstart or STop Antithrombotics Randomised Trial (RESTART) was a prospective, randomised, open-label, blinded endpoint, parallel-group trial at 122 hospitals in the UK. We recruited adults (≥18 years) who were taking antithrombotic (antiplatelet or anticoagulant) therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage, discontinued antithrombotic therapy, and survived for 24 h. Computerised randomisation incorporating minimisation allocated participants (1:1) to start or avoid antiplatelet therapy. We followed participants for the primary outcome (recurrent symptomatic intracerebral haemorrhage) for up to 5 years. We analysed data from all randomised participants using Cox proportional hazards regression, adjusted for minimisation covariates. This trial is registered with ISRCTN (number ISRCTN71907627). Findings: Between May 22, 2013, and May 31, 2018, 537 participants were recruited a median of 76 days (IQR 29–146) after intracerebral haemorrhage onset: 268 were assigned to start and 269 (one withdrew) to avoid antiplatelet therapy. Participants were followed for a median of 2·0 years (IQR [1·0– 3·0]; completeness 99·3%). 12 (4%) of 268 participants allocated to antiplatelet therapy had recurrence of intracerebral haemorrhage compared with 23 (9%) of 268 participants allocated to avoid antiplatelet therapy (adjusted hazard ratio 0·51 [95% CI 0·25–1·03]; p=0·060). 18 (7%) participants allocated to antiplatelet therapy experienced major haemorrhagic events compared with 25 (9%) participants allocated to avoid antiplatelet therapy (0·71 [0·39–1·30]; p=0·27), and 39 [15%] participants allocated to antiplatelet therapy had major occlusive vascular events compared with 38 [14%] allocated to avoid antiplatelet therapy (1·02 [0·65–1·60]; p=0·92). Interpretation: These results exclude all but a very modest increase in the risk of recurrent intracerebral haemorrhage with antiplatelet therapy for patients on antithrombotic therapy for the prevention of occlusive vascular disease when they developed intracerebral haemorrhage. The risk of recurrent intracerebral haemorrhage is probably too small to exceed the established benefits of antiplatelet therapy for secondary prevention