Improving inpatient care for older adults: implementing dementia commissioning for quality and innovation (CQUIN)

Dementia is a common condition, and people with dementia occupy around 25% of hospital beds. Commissioning for Quality and Innovation (CQUIN) is an NHS payment framework that links part of English healthcare providers’ income to quality improvement. The dementia CQUIN goals are designed to encourage the recognition of dementia in hospital. The Royal Surrey County Hospital, Guildford, introduced new procedures to meet the dementia CQUIN targets. Adherence to the changes was a problem. This project aimed to improve hospital’s implementation strategy. At baseline, completion rates for dementia CQUIN assessments were just 27%. Interventions were informed by semistructured interviews with junior doctors and dementia leads in neighbouring trusts. Progress was measured by regular audits and interventions were made over several months. Changes suggested by junior doctors and nurses proved very effective, and involving the multidisciplinary team produced the most significant improvement. Gradual progress was made until we achieved and maintained 90% completion for dementia assessments. In conclusion, we made changes to working practices to achieve the CQUIN targets and promoted quality care for older adults. Our experience highlighted the importance of involving multidisciplinary frontline staff in the design of service changes

Perplexities in Discrimination of Attention Deficit Hyperactivity Disorder (ADHD): Specific Behaviors that may hold some Answers

Attention deficit hyperactivity disorder (ADHD) is a source of diagnostic and intervention confusion and uncertainty for practitioners and parents. Questions creating some of the confusion were answered in a series of three studies. The sample was parent and teacher behavioral ratings for 389 children and 502 adolescents with ADHD and 3131 children and 3161 adolescents without ADHD in public and private schools and mental health clinics in forty states. In the first study, data was derived from participant T-scores on the Behavior Assessment System for Children (2nd ed.) to evaluate the construct validity using first and second order factor analyses. Sufficient construct validity was established. In the second study, descriptive discriminant analyses (DDA) and item level ANOVAs were used to investigate whether behaviors that discriminate between the target (i.e., ADHD) and comparison groups were associated with the primary symptoms, comorbid conditions, functional impairment, or some combination of the three. Analyses were completed using subscale T-scores and individual item scores from the target and comparison groups. Results were compared to determine if the behaviors that discriminated between the groups were consistent across developmental stages and between parents and teachers as raters. Primary symptoms, comorbid conditions, and functional impairment explained the variance as rated by parents and teachers. Primary symptoms were found to be the strongest discriminators of children and adolescents as rated by parents. Atypicality explained the largest variance (72.25%) between children and learning problems explained the largest variance (64.32%) between adolescents when rated by teachers. The third study was a literature review of intervention studies to increase the academic performance of youth with ADHD in light of the statistical significance controversy. Fifty-one single subject and group design studies of academic, behavioral, multimodal and parent training were found. Both sides of the statistical significance controversy were summarized. The method of result reporting for 23 group design studies was investigated. Seventy-seven percent of the studies reported results as ?significant? with 26% reporting effect sizes. Researchers are encouraged to report effect sizes and explicitly compare results to previous studies in order to establish replicability for ease of educator interpretation

From polygenic scores to precision medicine in Alzheimer’s Disease: A systematic review

Background: Late-onset Alzheimer’s Disease (AD) is highly heritable. The effect of many common genetic variants, single nucleotide polymorphisms (SNPs) confer risk. Variants are clustered in areas of biology, notably immunity and inflammation, cholesterol metabolism, endocytosis and ubiquitination. Polygenic scores (PRS), which weight the sum of an individual’s risk alleles, have been used to draw inferences about the pathological processes underpinning AD. Objective: This paper aims to systematically review how AD PRS are being used to study a range of outcomes and phenotypes related to neurodegeneration. Methods: We searched the literature from July 2008-July 2018 following PRISMA guidelines. Results: 57 studies met criteria. The AD PRS can distinguish AD cases from controls. The ability of AD PRS to predict conversion from Mild Cognitive Impairment (MCI) to AD was less clear. There was strong evidence of association between AD PRS and cognitive impairment. AD PRS were correlated with a number of biological phenotypes associated with AD pathology, such as neuroimaging changes and amyloid and tau measures. Pathway-specific polygenic scores were also associated with AD-related biologically relevant phenotypes. Conclusion: PRS can predict AD effectively and are associated with cognitive impairment. There is also evidence of association between AD PRS and other phenotypes relevant to neurodegeneration. The associations between pathway specific polygenic scores and phenotypic changes may allow us to define the biology of the disease in individuals and indicate who may benefit from specific treatments. Longitudinal cohort studies are required to test the ability of PGS to delineate pathway-specific disease activity

Imaging Alzheimer's genetic risk using Diffusion MRI: a systematic review

Diffusion magnetic resonance imaging (dMRI) is an imaging technique which probes the random motion of water molecules in tissues and has been widely applied to investigate changes in white matter microstructure in Alzheimer’s Disease. This paper aims to systematically review studies that examined the effect of Alzheimer’s risk genes on white matter microstructure. We assimilated findings from 37 studies and reviewed their diffusion pre-processing and analysis methods. Most studies estimate the diffusion tensor (DT) and compare derived quantitative measures such as fractional anisotropy and mean diffusivity between groups. Those with increased AD genetic risk are associated with reduced anisotropy and increased diffusivity across the brain, most notably the temporal and frontal lobes, cingulum and corpus callosum. Structural abnormalities are most evident amongst those with established Alzheimer’s Disease. Recent studies employ signal representations and analysis frameworks beyond DT MRI but show that dMRI overall lacks specificity to disease pathology. However, as the field advances, these techniques may prove useful in pre-symptomatic diagnosis or staging of Alzheimer’s disease

為取替申一札之事（助郷人馬請負証文、古山村役人宛）

Background Identifying the phenotypic manifestations of increased genetic liability for depression (MDD) and bipolar disorder (BD) can enhance understanding of their aetiology. The polygenic risk score (PRS) derived using data from genome-wide-association-studies can be used to explore how genetic risk is manifest in different samples. Aims In this systematic review, we review studies that examine associations between the MDD and BD polygenic risk scores and phenotypic outcomes. Methods Following PRISMA guidelines, we searched EMBASE, Medline and PsycINFO (from August 2009 – 14th March 2016) and references of included studies. Study inclusion was based on predetermined criteria and data were extracted independently and in duplicate. Results Twenty-five studies were included. Overall, both polygenic risk scores were associated with other psychiatric disorders (not the discovery sample disorder) such as depression, schizophrenia and bipolar disorder, greater symptom severity of depression, membership of a creative profession and greater educational attainment. Both depression and bipolar polygenic risk scores explained small amounts of variance in most phenotypes (< 2%). Limitations Many studies did not report standardised effect sizes. This prevented us from conducting a meta-analysis. Conclusions Polygenic risk scores for BD and MDD are associated with a range of phenotypes and outcomes. However, they only explain a small amount of the variation in these phenotypes. Larger discovery and adequately powered target samples are required to increase power of the PRS approach. This could elucidate how genetic risk for bipolar disorder and depression is manifest and contribute meaningfully to stratified medicine

Transcriptomic analysis of field-droughted sorghum from seedling to maturity reveals biotic and metabolic responses.

Drought is the most important environmental stress limiting crop yields. The C4 cereal sorghum [Sorghum bicolor (L.) Moench] is a critical food, forage, and emerging bioenergy crop that is notably drought-tolerant. We conducted a large-scale field experiment, imposing preflowering and postflowering drought stress on 2 genotypes of sorghum across a tightly resolved time series, from plant emergence to postanthesis, resulting in a dataset of nearly 400 transcriptomes. We observed a fast and global transcriptomic response in leaf and root tissues with clear temporal patterns, including modulation of well-known drought pathways. We also identified genotypic differences in core photosynthesis and reactive oxygen species scavenging pathways, highlighting possible mechanisms of drought tolerance and of the delayed senescence, characteristic of the stay-green phenotype. Finally, we discovered a large-scale depletion in the expression of genes critical to arbuscular mycorrhizal (AM) symbiosis, with a corresponding drop in AM fungal mass in the plants' roots

MADNESS: A Multiresolution, Adaptive Numerical Environment for Scientific Simulation

MADNESS (multiresolution adaptive numerical environment for scientific simulation) is a high-level software environment for solving integral and differential equations in many dimensions that uses adaptive and fast harmonic analysis methods with guaranteed precision based on multiresolution analysis and separated representations. Underpinning the numerical capabilities is a powerful petascale parallel programming environment that aims to increase both programmer productivity and code scalability. This paper describes the features and capabilities of MADNESS and briefly discusses some current applications in chemistry and several areas of physics

The impact of genetic risk for Alzheimer’s disease on the structural brain networks of young adults

INTRODUCTION: We investigated the structural brain networks of 562 young adults in relation to polygenic risk for Alzheimer’s disease, using magnetic resonance imaging (MRI) and genotype data from the Avon Longitudinal Study of Parents and Children. METHODS: Diffusion MRI data were used to perform whole-brain tractography and generate structural brain networks for the whole-brain connectome, and for the default mode, limbic and visual subnetworks. The mean clustering coefficient, mean betweenness centrality, characteristic path length, global efficiency and mean nodal strength were calculated for these networks, for each participant. The connectivity of the rich-club, feeder and local connections was also calculated. Polygenic risk scores (PRS), estimating each participant’s genetic risk, were calculated at genome-wide level and for nine specific disease pathways. Correlations were calculated between the PRS and (a) the graph theoretical metrics of the structural networks and (b) the rich-club, feeder and local connectivity of the whole-brain networks. RESULTS: In the visual subnetwork, the mean nodal strength was negatively correlated with the genome-wide PRS (r = –0.19, p = 1.4 × 10(–3)), the mean betweenness centrality was positively correlated with the plasma lipoprotein particle assembly PRS (r = 0.16, p = 5.5 × 10(–3)), and the mean clustering coefficient was negatively correlated with the tau-protein binding PRS (r = –0.16, p = 0.016). In the default mode network, the mean nodal strength was negatively correlated with the genome-wide PRS (r = –0.14, p = 0.044). The rich-club and feeder connectivities were negatively correlated with the genome-wide PRS (r = –0.16, p = 0.035; r = –0.15, p = 0.036). DISCUSSION: We identified small reductions in brain connectivity in young adults at risk of developing Alzheimer’s disease in later life

Why do women invest in pre-pregnancy health and care? A qualitative investigation with women attending maternity services

Background Despite the importance attributed to good pre-pregnancy care and its potential to improve pregnancy and child health outcomes, relatively little is known about why women invest in pre-pregnancy health and care. We sought to gain insight into why women invested in pre-pregnancy health and care. Methods We carried out 20 qualitative in-depth interviews with pregnant or recently pregnant women who were drawn from a survey of antenatal clinic attendees in London, UK. Interviewees were purposively sampled to include high and low investors in pre-pregnancy health and care, with variation in age, partnership status, ethnicity and pre-existing medical conditions. Data analysis was conducted using the Framework method. Results We identified three groups in relation to pre-pregnancy health and care: 1) The “prepared” group, who had high levels of pregnancy planning and mostly positive attitudes to micronutrient supplementation outside of pregnancy, carried out pre-pregnancy activities such as taking folic acid and making changes to diet and lifestyle. 2) The “poor knowledge” group, who also had high levels of pregnancy planning, did not carry out pre-pregnancy activities and described themselves as having poor knowledge. Elsewhere in their interviews they expressed a strong dislike of micronutrient supplementation. 3) The “absent pre-pregnancy period” group, had the lowest levels of pregnancy planning and also expressed anti-supplement views. Even discussing the pre-pregnancy period with this group was difficult as responses to questions quickly shifted to focus on pregnancy itself. Knowledge of folic acid was poor in all groups. Conclusion Different pre-pregnancy care approaches are likely to be needed for each of the groups. Among the “prepared” group, who were proactive and receptive to health messages, greater availability of information and better response from health professionals could improve the range of pre-pregnancy activities carried out. Among the “poor knowledge” group, better response from health professionals might yield greater uptake of pre-pregnancy information. A different, general health strategy might be more appropriate for the “absent pre-pregnancy period” group. The fact that general attitudes to micronutrient supplementation were closely related to whether or not women invested in pre-pregnancy health and care was an unanticipated finding and warrants further investigation.This report is independent research commissioned and funded by the Department of Health Policy Research Programme Pre-Pregnancy Health and Care in England: Exploring Implementation and Public Health Impact, 006/0068