COVID-19: UK frontline intensivists' emerging learning.

The Intensive Care Society held a webinar on 3 April 2020 at which representatives from 11 of the most COVID-19 experienced hospital trusts in England and Wales shared learning around five specific topic areas in an open forum. This paper summarises the emerging learning and practice shared by those frontline clinicians

Support at Home: Interventions to Enhance Life in Dementia (SHIELD) – evidence, development and evaluation of complex interventions

Background: Dementia is a national priority and this research addresses the Prime Minister’s commitment to dementia research as demonstrated by his 2020 challenge and the new UK Dementia Research Institute. In the UK > 800,000 older people have dementia. It has a major impact on the lives of people with dementia themselves, on the lives of their family carers and on services, and costs the nation £26B per year. Pharmacological cures for dementias such as Alzheimer’s disease are not expected before 2025. If no cure can be found, the ageing demographic will result in 2 million people living with dementia by 2050. People with dementia lose much more than just their memory and their daily living skills; they can also lose their independence, their dignity and status, their confidence and morale, and their roles both within the family and beyond. They can be seen as a burden by society, by their families and even by themselves, and may feel unable to contribute to society. This programme of research aims to find useful interventions to improve the quality of life of people with dementia and their carers, and to better understand how people with dementia can be supported at home and avoid being admitted to hospital. Objectives: (1) To develop and evaluate the maintenance cognitive stimulation therapy (MCST) for people with dementia; (2) to develop the Carer Supporter Programme (CSP), and to evaluate the CSP and Remembering Yesterday, Caring Today (RYCT) for people with dementia both separately and together in comparison with usual care; and (3) to develop a home treatment package (HTP) for dementia, to field test the HTP in practice and to conduct an exploratory trial. Methods: (1) The MCST programme was developed for people with dementia based on evidence and qualitative work. A randomised controlled trial (RCT) [with a pilot study of MCST plus acetylcholinesterase inhibitors (AChEIs)] compared MCST with cognitive stimulation therapy (CST) only. The MCST implementation study conducted a trial of outreach compared with usual care, and assessed implementation in practice. (2) The CSP was developed based on existing evidence and the engagement of carers of people with dementia. The RCT (with internal pilot) compared the CSP and reminiscence (RYCT), both separately and in combination, with usual care. (3) A HTP for dementia, including the most promising interventions and components, was developed by systematically reviewing the literature and qualitative studies including consensus approaches. The HTP for dementia was evaluated in practice by conducting in-depth field testing. Results: (1) Continuing MCST improved quality of life and improved cognition for those taking AChEIs. It was also cost-effective. The CST implementation studies indicated that many staff will run CST groups following a 1-day training course, but that outreach support helps staff go on to run maintenance groups and may also improve staff sense of competence in dementia care. The study of CST in practice found no change in cognition or quality of life at 8-month follow-up. (2) The CSP/RYCT study found no benefits for family carers but improved quality of life for people with dementia. RYCT appeared beneficial for the quality of life of people with dementia but at an excessively high cost. (3) Case management for people with dementia reduces admissions to long-term care and reduces behavioural problems. In terms of managing crises, staff suggested more costly interventions, carers liked education and support, and people with dementia wanted family support, home adaptations and technology. The easy-to-use home treatment manual was feasible in practice to help staff working in crisis teams to prevent hospital admissions for people with dementia. Limitations: Given constraints on time and funding, we were unable to compete the exploratory trial of the HTP package or to conduct an economic evaluation. Future research: To improve the care of people with dementia experiencing crises, a large-scale clinical trial of the home treatment manual is needed. Conclusion: There is an urgent need for effective psychosocial interventions for dementia. MCST improved quality of life and was cost-effective, with benefits to cognition for those on AChEIs. MCST was feasible in practice. Both CSP and RYCT improved the quality of life of people with dementia, but the overall costs may be too high. The HTP was useful in practice but requires evaluation in a full trial. Dementia care research may improve the lives of millions of people across the world. Trial registrations: Current Controlled Trials ISRCTN26286067 (MCST), ISRCTN28793457 (MCST implementation) and ISRCTN37956201 (CSP/RYCT). Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 5, No. 5. See the NIHR Journals Library website for further project information

Identifying Turbulent Spots in Transitional Boundary Layers

An artificial turbulent spot is simulated in a zero free-stream turbulence base flow and a base flow with organized streaks. Six identification methods are used in order to isolate the turbulent spot from the surrounding nonturbulent fluid. These are (i) instantaneous wall-normal velocity v, (ii) instantaneous spanwise velocity w, (iii) instantaneous turbulent dissipation, (iv) λ2 criterion, (v) Q criterion, and (vi) gradient of the finite time Lyapunov exponent. All methods are effective in isolating the turbulent spot from the streaks. The robustness of each technique is determined from the sensitivity of the maximum spot dimensions to changes in threshold level. The Q criterion shows the least sensitivity for the zero free-stream turbulence case and the instantaneous turbulent dissipation technique is least sensitive in the organized streaks case. For both cases the v technique was the most sensitive to changes in threshold level. © 2013 American Society of Mechanical Engineers

Physiological integration of roots and shoots in plant defense strategies links above- and belowground herbivory

Roots play a critical, but largely unappreciated, role in aboveground anti-herbivore plant defense (e.g. resistance and tolerance) and root–leaf connections may therefore result in unexpected coupling between above- and belowground consumers. Using the tobacco (Nicotiana tabacum) system we highlight two examples of this phenomenon. First, the secondary metabolite nicotine is produced in roots, yet translocated aboveground for use as a foliar resistance trait. We demonstrate that nematode root herbivory interferes with foliar nicotine dynamics, resulting in positive effects on aboveground phytophagous insects. Notably, nematode-induced facilitation only occurred on nicotine-producing plants, and not on nicotine-deficient mutants. In the second case, we use stable isotope and invertase enzyme analyses to demonstrate that foliar herbivory elicits a putative tolerance response whereby aboveground nutritional reserves are allocated to roots, resulting in facilitation of phytoparasitic nematodes. Thus, plants integrate roots in resistance and tolerance mechanisms for leaf defense, and such root–leaf connections inherently link the dynamics of above- and belowground consumers

Identifying turbulent spots in transitional boundary layers

An artificial turbulent spot is simulated in a zero free-stream turbulence base flow and a base flow with organised streaks. Six identification methods are used in order to isolate the turbulent spot from the surrounding non-turbulent fluid. These are (i) instantaneous wall-normal velocity, v′, (ii) instantaneous spanwise velocity, w′, (iii) instantaneous turbulent dissipation, (iv) λ2 - criterion, (v) Q - criterion and (vi) gradient of the Finite Time Lyapunov Exponent. All methods are effective in isolating the turbulent spot from the streaks. The robustness of each technique is determined from the sensitivity of the maximum spot dimensions to changes in threshold level. The Q-criterion shows the least sensitivity for the zero free-stream turbulence case and the instantaneous turbulent dissipation technique is least sensitive in the organised streaks case. For both cases the v′ technique was the most sensitive to changes in threshold level. Copyright © 2011 by ASME

Entropy generation rate in turbulent spots in a boundary layer subject to freestream turbulence

Turbulent spots are studied in a boundary layer subject to freestream turbulence with the data taken from direct numerical simulations performed by Brandt et al.[2]. Additional simulations of artificially induced turbulent spots are investigated in a laminar and streaky boundary layer. The flow is seperated into turbulent and non-turbulent regions using a threshold of spanwise velocity, w. Mean velocity profiles within the spot show siginificant deviations from fully turbulent profiles. The dissipation coefficient, indicating the evolution of entropy generation within the spot, shows good agreement with previous correlations. © 2010 Springer Science+Business Media B.V

Entropy generation rate in turbulent spots in a boundary layer subject to freestream turbulence

Turbulent spots are studied in a boundary layer subject to freestream turbulence with the data taken from direct numerical simulations performed by Brandt et al.[2]. Additional simulations of artificially induced turbulent spots are investigated in a laminar and streaky boundary layer. The flow is seperated into turbulent and non-turbulent regions using a threshold of spanwise velocity, w. Mean velocity profiles within the spot show siginificant deviations from fully turbulent profiles. The dissipation coefficient, indicating the evolution of entropy generation within the spot, shows good agreement with previous correlations. © 2010 Springer Science+Business Media B.V

Projections of care for older people with dementia in England: 2015 to 2040

Abstract Background The number of older people with dementia and the cost of caring for them, already substantial, are expected to rise due to population ageing. Objective This study makes projections of the number of older people with dementia receiving unpaid care or using care services and associated costs in England. Methods The study drew on up-to-date information for England from multiple sources including data from the CFASII study, output from the PACSim dynamic microsimulation model, Office for National Statistics population projections and data from the MODEM cohort study. A simulation model was built to make the projections. Results We project that the number of older people with dementia will more than double in the next 25 years. The number receiving unpaid or formal care is projected to rise by 124%, from 530,000 in 2015 to 1,183,000 in 2040. Total cost of dementia is projected to increase from £23.0 billion in 2015 to £80.1 billion in 2040, and average cost is projected to increase from £35,100 per person per year in 2015 to £58,900 per person per year in 2040. Total and average costs of social care are projected to increase much faster than those of healthcare and unpaid care. Conclusion The numbers of people with dementia and associated costs of care will rise substantially in the coming decades, unless new treatments enable the progression of the condition to be prevented or slowed. Care and support for people with dementia and their family carers will need to be increased. </jats:sec