Defining the outcomes of community care: the perspectives of older people with dementia and their carers

There is growing recognition of the need for outcome measures which reflect the aims of services for people with dementia. The development and application of existing outcome measures has often marginalised people with dementia. ‘Experts’ and carers have been viewed as primary sources when identifying relevant outcomes or domains of quality of life, and proxy respondents have often been responsible for rating outcomes on the resulting measures. This paper reports a small consultation with people with dementia and their carers to identify the desired outcomes of community care. While there was considerable overlap in the outcomes identified by people with dementia and their carers, a number of limitations of relying solely on carers as proxy respondents were identified. A key outcome, which has been relatively neglected in previous work, was maximising a sense of autonomy. A range of outcomes related to the ways in which services are delivered were also identified. Future evaluative studies should encompass both quality-of-life outcomes and service-process outcomes (the impacts of the ways in which services are delivered) in addition to other outcome measures relevant to the aims and objectives of the service

Systematic review of the evidence for rational dosing of colistin

Background. There is an alarming global increase in the incidence of nosocomial infections with multidrug-resistant Gram-negative bacteria, which are often only susceptible to colistin. Colistin was developed prior to current methods of establishing dosing using pharmacokinetic-pharmacodynamic relationships. Dosing regimens differ in package inserts from different manufacturers and in different guidelines. It is imperative to avoid under-dosing with colistin in order to limit the development of resistance, as it is the last line of defence. Methods. We conducted a systematic review of the literature to develop guidelines for rational dosing of intravenous colistin, with a particular focus on critically ill patients. Results. Colistin is administered as the inactive pro-drug colistimethate sodium. Colistin demonstrates concentration-dependent bacterial killing, suggesting that higher doses should be administered less frequently to achieve higher peak concentrations. Dose-related nephrotoxicity occurs, making it impossible to safely achieve concentrations that prevent the selection of resistant mutants or the effective eradication of bacteria with higher minimum inhibitory concentrations. Theoretically, combination therapy should be used to reduce the risk of selection of resistant bacteria. In critically ill patients, a loading dose should be given to rapidly achieve therapeutic concentrations, followed by maintenance doses of 4.5 MU 12-hourly. Maintenance dose adjustment is necessary with renal impairment. Conclusion. Easier access to colistin is needed in South Africa, where it is not a registered medicine. Further research is needed to better characterise colistin’s pharmacokinetic-pharmacodynamic relationships in humans and to establish whether combinations of colistin with other antimicrobials result in improved clinical outcomes or a reduction in selection of resistant bacteria

Systematic review of the evidence for rational dosing of colistin

BACKGROUND: There is an alarming global increase in the incidence of nosocomial infections with multidrug-resistant Gram-negative bacteria, which are often only susceptible to colistin. Colistin was developed prior to current methods of establishing dosing using pharmacokinetic-pharmacodynamic relationships. Dosing regimens differ in package inserts from different manufacturers and in different guidelines. It is imperative to avoid under-dosing with colistin in order to limit the development of resistance, as it is the last line of defence. METHODS: We conducted a systematic review of the literature to develop guidelines for rational dosing of intravenous colistin, with a particular focus on critically ill patients. RESULTS: Colistin is administered as the inactive pro-drug colistimethate sodium. Colistin demonstrates concentration-dependent bacterial killing, suggesting that higher doses should be administered less frequently to achieve higher peak concentrations. Dose-related nephrotoxicity occurs, making it impossible to safely achieve concentrations that prevent the selection of resistant mutants or the effective eradication of bacteria with higher minimum inhibitory concentrations. Theoretically, combination therapy should be used to reduce the risk of selection of resistant bacteria. In critically ill patients, a loading dose should be given to rapidly achieve therapeutic concentrations, followed by maintenance doses of 4.5 MU 12-hourly. Maintenance dose adjustment is necessary with renal impairment. CONCLUSION: Easier access to colistin is needed in South Africa, where it is not a registered medicine. Further research is needed to better characterise colistin's pharmacokinetic-pharmacodynamic relationships in humans and to establish whether combinations of colistin with other antimicrobials result in improved clinical outcomes or a reduction in selection of resistant bacteria

Overcoming the false-minima problem in direct methods: Structure determination of the packaging enzyme P4 from bacteriophage φ13

The problems encountered during the phasing and structure determination of the packaging enzyme P4 from bacteriophage φ13 using the anomalous signal from selenium in a single-wavelength anomalous dispersion experiment (SAD) are described. The oligomeric state of P4 in the virus is a hexamer (with sixfold rotational symmetry) and it crystallizes in space group C2, with four hexamers in the crystallographic asymmetric unit. Current state-of-the-art ab initio phasing software yielded solutions consisting of 96 atoms arranged as sixfold symmetric clusters of Se atoms. However, although these solutions showed high correlation coefficients indicative that the substructure had been solved, the resulting phases produced uninterpretable electron-density maps. Only after further analysis were correct solutions found (also of 96 atoms), leading to the eventual identification of the positions of 120 Se atoms. Here, it is demonstrated how the difficulties in finding a correct phase solution arise from an intricate false-minima problem. © 2005 International Union of Crystallography - all rights reserved

Packaging redesign – benefits for the environment and the community

This paper aims to underline the importance of the packaging redesign process and the potential benefits that can be derived from this for both the environment and the community. The research demonstrates that the redesign of paper corrugated packaging has cost savings for most links of the supply chain such as the industrial customers, retailers, wholesalers and final consumers. In addition, an applied case study will be used that aims to provide evidence that the redesign process could further offer weight and transportation benefits, provide better environmental performance and finally offer better protection for the packaged products. The alternative packaging suggestions made in the research refer to the secondary paper corrugated packaging since the objective is to show the value of the redesign process. The research provides the tools for a packaging designer, on how to estimate, analyse, redesign and compare different approaches, finding the way to a more sustainable packaging supply chain

Appropriate disclosure of a diagnosis of dementia : identifying the key behaviours of 'best practice'

Background: Despite growing evidence that many people with dementia want to know their diagnosis, there is wide variation in attitudes of professionals towards disclosure. The disclosure of the diagnosis of dementia is increasingly recognised as being a process rather than a one-off behaviour. However, the different behaviours that contribute to this process have not been comprehensively defined. No intervention studies to improve diagnostic disclosure in dementia have been reported to date. As part of a larger study to develop an intervention to promote appropriate disclosure, we sought to identify important disclosure behaviours and explore whether supplementing a literature review with other methods would result in the identification of new behaviours. Methods: To identify a comprehensive list of behaviours in disclosure we conducted a literature review, interviewed people with dementia and informal carers, and used a consensus process involving health and social care professionals. Content analysis of the full list of behaviours was carried out. Results: Interviews were conducted with four people with dementia and six informal carers. Eight health and social care professionals took part in the consensus panel. From the interviews, consensus panel and literature review 220 behaviours were elicited, with 109 behaviours over-lapping. The interviews and consensus panel elicited 27 behaviours supplementary to the review. Those from the interviews appeared to be self-evident but highlighted deficiencies in current practice and from the panel focused largely on balancing the needs of people with dementia and family members. Behaviours were grouped into eight categories: preparing for disclosure; integrating family members; exploring the patient's perspective; disclosing the diagnosis; responding to patient reactions; focusing on quality of life and well-being; planning for the future; and communicating effectively. Conclusion: This exercise has highlighted the complexity of the process of disclosing a diagnosis of dementia in an appropriate manner. It confirms that many of the behaviours identified in the literature (often based on professional opinion rather than empirical evidence) also resonate with people with dementia and informal carers. The presence of contradictory behaviours emphasises the need to tailor the process of disclosure to individual patients and carers. Our combined methods may be relevant to other efforts to identify and define complex clinical practices for further study.This project is funded by UK Medical Research Council, Grant reference number G0300999

Galaxy Zoo Builder: Four-component Photometric Decomposition of Spiral Galaxies Guided by Citizen Science

Multicomponent modeling of galaxies is a valuable tool in the effort to quantitatively understand galaxy evolution, yet the use of the technique is plagued by issues of convergence, model selection, and parameter degeneracies. These issues limit its application over large samples to the simplest models, with complex models being applied only to very small samples. We attempt to resolve this dilemma of "quantity or quality"by developing a novel framework, built inside the Zooniverse citizen-science platform, to enable the crowdsourcing of model creation for Sloan Digital Sky Survey galaxies. We have applied the method, including a final algorithmic optimization step, on a test sample of 198 galaxies, and examine the robustness of this new method. We also compare it to automated fitting pipelines, demonstrating that it is possible to consistently recover accurate models that either show good agreement with, or improve on, prior work. We conclude that citizen science is a promising technique for modeling images of complex galaxies, and release our catalog of models

Galaxy Zoo: constraining the origin of spiral arms

Since the discovery that the majority of low-redshift galaxies exhibit some level of spiral structure, a number of theories have been proposed as to why these patterns exist. A popular explanation is a process known as swing amplification, yet there is no observational evidence to prove that such a mechanism is at play. By using a number of measured properties of galaxies, and scaling relations where there are no direct measurements, we model samples of SDSS and S4G spiral galaxies in terms of their relative halo, bulge and disc mass and size. Using these models, we test predictions of swing amplification theory with respect to directly measured spiral arm numbers from Galaxy Zoo 2. We find that neither a universal cored or cuspy inner dark matter profile can correctly predict observed numbers of arms in galaxies. However, by invoking a halo contraction/expansion model, a clear bimodality in the spiral galaxy population emerges. Approximately 40 per cent of unbarred spiral galaxies at z 10^10 Msolar have spiral arms that can be modelled by swing amplification. This population display a significant correlation between predicted and observed spiral arm numbers, evidence that they are swing amplified modes. The remainder are dominated by two-arm systems for which the model predicts significantly higher arm numbers. These are likely driven by tidal interactions or other mechanisms

Developing an intervention for fall-related injuries in dementia (DIFRID): an integrated, mixed-methods approach

This is the final version. Available on open access from BMC via the DOI in this recordThe datasets generated during and/or analysed during the current study are available from the corresponding author (LA) on reasonable request. The data are not publicly available due to them containing information that could compromise research participant confidentialityBackground: Falls in people with dementia can result in a number of physical and psychosocial consequences. However, there is limited evidence to inform how best to deliver services to people with dementia following a fall. The aim of the DIFRID study was to determine the feasibility of developing and implementing a new intervention to improve outcomes for people with dementia with fall-related injuries; this encompasses both short-term recovery and reducing the likelihood of future falls. This paper details the development of the DIFRID intervention. Methods: The intervention was designed using an integrated, mixed-methods approach. This involved a realist synthesis of the literature and qualitative data gathered through interviews and focus groups with health and social care professionals (n=81). An effectiveness review and further interviews and observation were also conducted and are reported elsewhere. A modified Delphi panel approach with 24 experts was then used to establish a consensus on how the findings should translate into a new intervention. After feedback from key stakeholders (n=15) on the proposed model, the intervention was manualised and training developed. Results: We identified key components of a new intervention covering three broad areas: • Ensuring that the circumstances of rehabilitation are optimised for people with dementia • Compensating for the reduced ability of people with dementia to self-manage • Equipping the workforce with the necessary skills and information to care for this patient group Consensus was achieved on 54 of 69 statements over two rounds of the Delphi surveys. The statements were used to model the intervention and finalise the accompanying manual and protocol for a feasibility study. Stakeholder feedback was generally positive and the majority of suggested intervention components were approved. The proposed outcome was a 12-week complex multidisciplinary intervention primarily based at the patient’s home. Conclusions: A new intervention has been developed to improve outcomes for people with dementia following a fall requiring healthcare attention. The feasibility of this intervention is currently being tested.National Institute for Health Research (NIHR

Galaxy and mass assembly (GAMA) : The wavelength-dependent sizes and profiles of galaxies revealed by MegaMorph

We investigate the relationship between colour and structure within galaxies using a large, volume-limited sample of bright, low-redshift galaxies with optical-near-infrared imaging from the Galaxy AndMass Assembly survey.We fit single-component,wavelength-dependent, elliptical Sérsic models to all passbands simultaneously, using software developed by the MegaMorph project. Dividing our sample by n and colour, the recovered wavelength variations in effective radius (Re) and Sérsic index (n) reveal the internal structure, and hence formation history, of different types of galaxies. All these trends depend on n; some have an additional dependence on galaxy colour. Late-type galaxies (nr 2.5), even though they maintain constant n with wavelength, revealing that ellipticals are a superimposition of different stellar populations associated with multiple collapse and merging events. Processes leading to structures with larger Re must be associated with lower metallicity or younger stellar populations. This appears to rule out the formation of young cores through dissipative gas accretion as an important mechanism in the recent lives of luminous elliptical galaxies.Peer reviewe