Evidence-based interventions in dementia: A pragmatic cluster-randomised trial of an educational intervention to promote earlier recognition and response to dementia in primary care (EVIDEM-ED)

Background: The National Dementia Strategy seeks to enhance general practitioners' diagnostic and management skills in dementia. Early diagnosis in dementia within primary care is important as this allows those with dementia and their family care networks to engage with support services and plan for the future. There is, however, evidence that dementia remains under-detected and sub-optimally managed in general practice. An earlier unblinded, cluster randomised controlled study tested the effectiveness of educational interventions in improving detection rates and management of dementia in primary care. In this original trial, a computer decision support system and practice-based educational workshops were effective in improving rates of detecting dementia although not in changing clinical management. The challenge therefore is to find methods of changing clinical management. Our aim in this new trial is to test a customised educational intervention developed for general practice, promoting both earlier diagnosis and concordance with management guidelines.Design/Method: The customised educational intervention combines practice-based workshops and electronic support material. Its effectiveness will be tested in an unblinded cluster randomised controlled trial with a pre-post intervention design, with two arms; normal care versus the educational intervention. Twenty primary care practices have been recruited with the aim of gaining 200 patient participants. We will examine whether the intervention is effective, pragmatic and feasible within the primary care setting. Our primary outcome measure is an increase in the proportion of patients with dementia who receive at least two dementia-specific management reviews per year. We will also examine important secondary outcomes such as practice concordance with management guidelines and benefits to patients and carers in terms of quality of life and carer strain.Discussion: The EVIDEM-ED trial builds on the earlier study but the intervention is different in that it is specifically customised to the educational needs of each practice. If this trial is successful it could have implications for the implementation of the National Dementia Strategy

Toward a Unified Science of the Earth\u27s Surface: Opportunities for Synthesis Among Hydrology, Geomorphology, Geochemistry, and Ecology

The Earth\u27s surface is shaped by the interaction of tectonics, water, sediment, solutes, and biota over a wide range of spatial and temporal scales and across diverse environments. Development of a predictive science of Earth surface dynamics integrates many disciplines and approaches, including hydrology, geomorphology, ocean and atmospheric science, sedimentary and structural geology, geochemistry, and ecology. This paper discusses challenges, opportunities, and a few example problems that can serve as pathways toward this integration

A sustainable path for space science

High-performance scientific satellites are currently the exclusive domain of government-funded agencies. The team behind the Twinkle Space Mission is developing a new class of small and sustainable science satellites that leverages recent innovations in the commercial space sector

Case management for people with dementia and its translations: A discussion paper

Case management is generally seen as a way to provide efficient, cost-saving person-centred care for people with dementia by connecting together fragmented services, but the available evidence in favour of its merits is often considered inconclusive, unclear and sketchy. This discussion paper investigates the evidence of the benefit of case management for people with dementia and explores the complexity of the concept and the experiences of its implementation. It offers a comprehensive framework for conceptualising various types of case management and asks the question: who can be a case manager? Building on examples from three European countries it addresses the problem of the expansion and adoption of the case management method. It compares the conventional model of diffusion of innovation with the ideas of interessement and co-constitution and envisions a successful model of case management as a fluid technology that is both friendly and flexible, allowing it to adapt to different settings and systems

Mapping the column density and dust temperature structure of IRDCs with Herschel

Infrared dark clouds (IRDCs) are cold and dense reservoirs of gas potentially available to form stars. Many of these clouds are likely to be pristine structures representing the initial conditions for star formation. The study presented here aims to construct and analyze accurate column density and dust temperature maps of IRDCs by using the first Herschel data from the Hi-GAL galactic plane survey. These fundamental quantities, are essential for understanding processes such as fragmentation in the early stages of the formation of stars in molecular clouds. We have developed a simple pixel-by-pixel SED fitting method, which accounts for the background emission. By fitting a grey-body function at each position, we recover the spatial variations in both the dust column density and temperature within the IRDCs. This method is applied to a sample of 22 IRDCs exhibiting a range of angular sizes and peak column densities. Our analysis shows that the dust temperature decreases significantly within IRDCs, from background temperatures of 20-30 K to minimum temperatures of 8-15 K within the clouds, showing that dense molecular clouds are not isothermal. Temperature gradients have most likely an important impact on the fragmentation of IRDCs. Local temperature minima are strongly correlated with column density peaks, which in a few cases reach NH2 = 1 x 10^{23} cm^{-2}, identifying these clouds as candidate massive prestellar cores. Applying this technique to the full Hi-GAL data set will provide important constraints on the fragmentation and thermal properties of IRDCs, and help identify hundreds of massive prestellar core candidates.Comment: Accepted for publication in A&A Herschel special issu

Geochemistry of Vein Calcites Hosted in the Troodos Pillow Lavas and Their Implications for the Timing and Physicochemical Environment of Fracturing, Fluid Circulation, and Vein Mineral Growth

Calcite veins hosted in pillow lavas of the Late Cretaceous Troodos suprasubduction zone ophiolite provide insights into the timing and physicochemical environment of postmagmatic fracturing and fluid circulation through oceanic crust. This study presents rare earth element and yttrium (REE+Y) concentrations, δ13C, δ18O, 87Sr/86Sr, and clumped isotopic (Δ47) compositions of vein calcites in order to investigate their fluid sources, formation temperatures, and precipitation ages. These geochemical data are combined with microtextural analyses. Intersections of 87Sr/86Sr ratios of vein calcites with the Sr isotope seawater curve suggest two distinct calcite veining phases. Major calcite veining within an interval of ~10 Myr after crust formation is characterized by microtextures that point to extensional fracturing related to crack and sealing, host rock brecciation, and advective fluid flow. These vein calcites show REE+Y characteristics, 87Sr/86Sr ratios, and clumped isotopic compositions indicative of precipitation from seawater at <50 °C. Extended fluid residence times intensified fluid‐rock interactions and lowered Y/Ho ratios of some blocky vein calcites, whereas crack and sealing resulted in pristine seawater signatures. Low 87Sr/86Sr ratios of localized high‐temperature blocky vein calcites point to the involvement of hydrothermal fluids. These calcites show Mn‐controlled oscillatory growth zonations that probably developed in a closed system out of equilibrium. Later calcite veining (<75 Ma) may have coincided with rotation and/or uplift of the Troodos ophiolite. Microtextures of these vein calcites indicate fluid diffusion and fracture‐independent crystallization pressure‐driven veining. Their variably modified seawater signatures resulted from diffusion‐related fluid interaction with hydrothermal sediments

Immune complex formation impairs the elimination of solutes from the brain: implications for immunotherapy in Alzheimer's disease

Background: Basement membranes in the walls of cerebral capillaries and arteries form a major lymphatic drainage pathway for fluid and solutes from the brain. Amyloid-β (Aβ) draining from the brain is deposited in such perivascular pathways as cerebral amyloid angiopathy (CAA) in Alzheimer's disease (AD). CAA increases in severity when Aβ is removed from the brain parenchyma by immunotherapy for AD. In this study we investigated the consequences of immune complexes in artery walls upon drainage of solutes similar to soluble Aβ. We tested the hypothesis that, following active immunization with ovalbumin, immune complexes form within the walls of cerebral arteries and impair the perivascular drainage of solutes from the brain. Mice were immunized against ovalbumin and then challenged by intracerebral microinjection of ovalbumin. Perivascular drainage of solutes was quantified following intracerebral microinjection of soluble fluorescent 3kDa dextran into the brain at different time intervals after intracerebral challenge with ovalbumin. Results: Ovalbumin, IgG and complement C3 co-localized in basement membranes of artery walls 24 hrs after challenge with antigen; this was associated with significantly reduced drainage of dextran in immunized mice. Conclusions: Perivascular drainage along artery walls returned to normal by 7 days. These results indicate that immune complexes form in association with basement membranes of cerebral arteries and interfere transiently with perivascular drainage of solutes from the brain. Immune complexes formed during immunotherapy for AD may similarly impair perivascular drainage of soluble Aβ and increase severity of CAA

Quantifying the Quiet Epidemic: Diagnosing Dementia in Twentieth Century Britain

During the late 20(th) century numerical rating scales became central to the diagnosis of dementia and helped transform attitudes about its causes and prevalence. Concentrating largely on the development and use of the Blessed Dementia Scale, I argue that rating scales served professional ends during the 1960s and 1970s. They helped old age psychiatrists establish jurisdiction over conditions such as dementia and present their field as a vital component of the welfare state, where they argued that ‘reliable modes of diagnosis’ were vital to the allocation of resources. I show how these arguments appealed to politicians, funding bodies and patient groups, who agreed that dementia was a distinct disease and claimed research on its causes and prevention should be designated ‘top priority’. But I also show that worries about the replacement of clinical acumen with technical and depersonalized methods, which could conceivably be applied by anyone, led psychiatrists to stress that rating scales had their limits and could be used only by trained experts

Artificial drainage of peatlands: hydrological and hydrochemical process and wetland restoration

Peatlands have been subject to artificial drainage for centuries. This drainage has been in response to agricultural demand, forestry, horticultural and energy properties of peat and alleviation of flood risk. However, the are several environmental problems associated with drainage of peatlands. This paper describes the nature of these problems and examines the evidence for changes in hydrological and hydrochemical processes associated with these changes. Traditional black-box water balance approaches demonstrate little about wetland dynamics and therefore the science of catchment response to peat drainage is poorly understood. It is crucial that a more process-based approach be adopted within peatland ecosystems. The environmental problems associated with peat drainage have led, in part, to a recent reversal in attitudes to peatlands and we have seen a move towards wetland restoration. However, a detailed understanding of hydrological, hydrochemical and ecological process-interactions will be fundamental if we are to adequately restore degraded peatlands, preserve those that are still intact and understand the impacts of such management actions at the catchment scale