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

The effect of reagent rotation on gas phase reactions

This dissertation examines the effect of reagent rotation in elementary gas phase reactions. Historically, the effect of rotational excitation of the reagents of a chemical reaction on the reactive cross section has been poorly understood. One of the major reasons for this was the lack of a simple model in which the dynamics could be visualized. In this work, such a model is developed and utilized in order to elucidate trends in reactivity observed upon rotational excitation. Within the context of this model, exact quantum mechanical scattering calculations are performed for a simple atom-diatom system. These exact quantum mechanical probabilities of reaction as a function of rotational quantum number, P\sp{\rm R}(j), exhibit the characteristic dip and climb behavior observed in many classical trajectory calculations. These exact P\sp{\rm R}(j) are then compared to P\sp{\rm R}(j) obtained via several approximate quantum mechanical methods, for example, the Centrifugal Sudden (CS) and the Infinite Order Sudden (IOS). We find that, in general, the CS method does a good job reproducing exact P\sp{\rm R}(j). In contrast, the IOS method only reproduces the correct qualitative trends when the collision is sudden like. The applicability of classical mechanics as it relates to rotational excitation is also investigated. Classical P\sp{\rm R}(j) obtained using the model are compared to the exact quantum mechanical P\sp{\rm R}(j). The viability of several classical mechanical approximate scattering techniques is also investigated. The classical CS approximation reproduces qualitative trends observed in the exact classical P\sp{\rm R}(j), while the classical IOS only reproduces the correct qualitative trends under sudden conditions. Having established the accuracy of classical mechanics in dealing with rotational excitation we then utilized it to fully define the phenomena responsible for the trends observed in the classical P\sp{\rm R}(j). Lastly, full 3D classical trajectories are carried out for the F + H\sb2(0,j) and OH(0,j) + H\sb2(0,j\sp\prime) reactions. The model qualitatively reproduces the trends observed in the classical reaction cross section as a function of j, S\sp{\rm R}(j), for both reactions

Anticipating, Preventing, and Surviving Secondary Boycotts

Even the best stakeholder-managed firms can suffer when they become the targets of a secondary boycott, as recent headlines attest. A secondary boycott is a group’s refusal to engage a target firm with which the group has no direct dispute in an attempt to sway public opinion, draw attention to an issue, or influence the actions of a disputant. This article provides a new perspective and tools for both scholars and managers concerned with this phenomenon. Building on a stakeholder theory foundation, we examine possible actions managers can take to avoid being surprised by a secondary boycott, propose conditions that raise the probability of becoming the target of a secondary boycott, and develop four alternative approaches for managing stakeholder relationships in a world of secondary boycotts, consistent with the underlying stakeholder culture of the firm

Exploring brain structure and blood metabolic profiles using Alzheimer's pathway specific polygenic risk scores

Alzheimer’s disease (AD) is a progressive neurodegenerative disorder that affects older people. It is common, affecting around one in ten people over 65 years old. In addition to the autosomal dominant AD genes and Apolipoprotein E (APOE), genome wide association studies (GWAS) have identified a number of small risk loci. These can be combined into polygenic risk scores (PRS) which can predict AD relatively accurately and are associated with a number of neurodegeneration phenotypes. Pathway analyses of GWAS data have implicated a number of biological processes, including the immune response and lipid metabolism. How AD pathway specific genetic burden manifests in brain structure or serum metabolic profiles is not well understood. In this thesis, volumetric and diffusion MRI and serum lipid and inflammatory markers were used to investigate manifestations of AD polygenic risk in two large population cohorts. Specifically, these analyses sought to determine 1) whether AD polygenic risk scores were associated with neuroimaging and blood marker phenotypes linked to neurodegeneration in younger and older adult cohorts; and 2) whether PRS informed by disease pathways were associated with different patterns of alteration in brain structure, serum lipids or inflammatory markers. The relationships between PRS and phenotypes were explored using linear regression. There were significant associations between pathway specific PRS, grey matter volumes and white matter microstructure. Although some of these attenuated when the APOE region was excluded from the score, some were maintained, in particular cortical thickness in mature adults, which appeared to be independent of APOE. Increased pathway specific polygenic risk for AD was also associated with serum markers such as increased blood lipids, particularly low density lipoprotein (LDL) cholesterol and total cholesterol, and decreased C-Reactive Protein (CRP). However, these effects seemed to be driven by the APOE locus. Further longitudinal studies, combining advanced MRI techniques with cerebrospinal fluid and neuroradiology biomarkers, will be required to confirm these findings and assess their biological significance

The Research Informed Teaching Project at Staffordshire University 2013-2016: Conference Paper: Enhancing Students’ Skills Development in Contract Law through an Online Simulation (MLX)

Description of Session & Abstract. In this session at the Association of Law Teachers (ALT) annual conference 2016, members of the RiT project team and colleagues from Pearson Education, notably Kerry George and Prof. Stephen Gomez - who have been working with the SU RiT team - presented preliminary finding from a collaborative study of the use of a new digital, online learning resource called MyLegalExperience (MLX) to assist student learning in Contract Law. The presentation drew on the work of Judith Tillson, lead researcher for the work being done with Pearson on MLX, and Prof Stephen Gomez. The session started with some background, describing the challenges faced with traditional teaching methods of applying Contract Law to practical advice needs for clients; and then explaining the use of an online system to address these challenges. Emphasis was placed on how collaboration between tutor, student and content provider can be facilitated through technology. As well as a demonstration, questions from delegates were taken by the presenters. Abstract. The RiT project has been interested in a range of issues since it started in 2013, including the support that Law students get from on-line systems and services which support their research, teaching, and learning, and the application of knowledge. Previous presentations by the team at ALT conferences, including those at Nottingham and Cardiff, have been concerned with the use of on-lines systems and the development and deployment of research and research-related skills, and assessment aspects. The MLX project focuses on the problems students can have with putting their knowledge into practice, for instance when advising clients about legal matters. The context is that students are requesting more opportunities to practice and to obtain greater feedback, including more individual, personalised comments from tutors. With the increase in student numbers, all these requirements have an impact on tutor workload. New internet technologies have the potential for addressing these issues but lecturers either do not have the time or web skills to produce sophisticated online systems at a standard expected by their students who are used to professional software on the internet. The RiT project team, notably Judith Tillson, have teamed up with Pearson, the education publishers, to consider these challenges, and to trial MLX. The MLX system provides an online simulation designed to support students’ engagement and skills development in Contract Law across 6 topics. However, only two topics have been used in this particular trial, as it has been managed by Judith. In each topic, students play a legal advisory role, and complete practical tasks in response to the issues raised by a fictional client. Each topic consists of four scaffolded activities that build up in complexity as students work through them. The activities are: 1. Issue spotting - students answer a series of self-assessed MCQs (multiple choice questions) to identify the legal issues and legal principles from the facts related to Contract Law. 2. Analysing the Law - students fill in the blanks to identify the legal issues and legal principles from the facts. 3. Applying legal advice – this involves a practical task designed to put knowledge into practice by students uploading a piece of work which is then marked by the lecturer who gives feedback to be used to feed forward as assessment for learning as the basis of the fourth activity below. 4. Reflection- model answer and reflective MCQs to compare work completed in activity 3 to the model answer to facilitate self-assessment as a link to self-organised learning. Judith and the team have been exploring the effectiveness or efficacy of MLX in supporting learning through a simulation in the manner described above. Though we are using a specific learning resource (i.e. MLX) in the study, it is intended that we will establish a pedagogy that can be applied in other contexts. The project has been run by Judith in a live module in 2015-16 using a mix of qualitative and quantitative methods to assess students’ attitudes and perspectives, as well as data analytics to measure student engagement and performance both in MLX and in summative module assignments. Judith has also been using an innovative Twitter approach to charting student attitudes throughout their usage of MLX. Project Findings. Preliminary findings were provided in the course of the presentation. Further work is being undertaken by Judith and Christine, and it is hoped the results will feature in an article in The Law Teacher in 2017-18 and in other outputs

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

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

Alzheimer's disease: the amyloid hypothesis on trial

The pathogenesis of Alzheimer's disease is complex. The amyloid hypothesis has directed research efforts for many years, but it has recently been questioned after failed drug trials. Here, we review the evidence for and against and suggest that it might be premature to abandon the amyloid hypothesis

Score reading and retention of twentieth-century compositions : effects of conventional notation, graphic notation, and improvisation on aural perception

This study was an investigation of the use of a nontraditional visual aid, graphic notation, in the aural perception of 20th-century music. Tests on score reading and retention were administered to fourth graders, eighth graders, and college non-music majors. Subjects, grouped according to different methods of presentation, (l) listened while viewing conventional scores, (2) listened while viewing graphic scores, and (3) participated in improvisatory activities using graphic techniques and then listened while viewing graphic scores. Experimenter-constructed graphic scores of excerpts from three 20th-century woodwind quintets by Hindemith, Chavez, and Schuller, were contrasted with conventional scores of the same works. Pitch was represented on the vertical axis, time on the horizontal axis; a different color was used for each instrument