New horizons: the management of hypertension in people with dementia

The optimal management of hypertension in people with dementia is uncertain. This review explores if people with dementia experience greater adverse effects from antihypertensive medications, if cognitive function is protected or worsened by controlling blood pressure (BP) and if there are subgroups of people with dementia for whom antihypertensive therapy is more likely to be harmful. Robust evidence is scant, trials of antihypertensive medications have generally excluded those with dementia. Observational data show changes in risk association over the life course, with high BP being a risk factor for cognitive decline in mid-life, while low BP is predictive in later life. It is therefore possible that excessive BP lowering in older people with dementia might harm cognition. From the existing literature, there is no direct evidence of benefit or harm from treating hypertension in people with dementia. So what practical steps can the clinician take? Assess capacity, establish patient preferences when making treatment decisions, use ambulatory monitoring to thoroughly assess BP, individualise and consider deprescribing where side effects (e.g. hypotension) outweigh the benefits. Future research might include pragmatic randomised trials of targeted deprescribing, which include patient-centred outcome measures to help support decision-making and studies to address mechanistic uncertainties

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Siliceous microfossil assemblage and accumulation rate variations across the Middle Eocene Climatic Optimum at ODP Site 171-1051

The Middle Eocene Climatic Optimum (MECO; ~ 40 million years ago [Ma]) is one of the most prominent transient global warming events in the Paleogene. Although the event is well documented in geochemical and isotopic proxy records at many locations, the marine biotic response to the MECO remains poorly constrained. We present new high-resolution, quantitative records of siliceous microplankton assemblages from the MECO interval of Ocean Drilling Program (ODP) Site 1051 in the subtropical western North Atlantic Ocean, which are interpreted in the context of published foraminiferal and bulk carbonate stable isotope (d18O and d13C) records. High diatom, radiolarian and silicoflagellate accumulation rates between 40.5 and 40.0 Ma are interpreted to reflect an ~ 500 thousand year (kyr) interval of increased nutrient supply and resultant surface-water eutrophication that was associated with elevated sea-surface temperatures during the prolonged onset of the MECO. Relatively low pelagic siliceous phytoplankton sedimentation accompanied the peak MECO warming interval and the termination of the MECO during an ~ 70 kyr interval centered at ~ 40.0 Ma. Following the termination of the MECO, an ~ 200-kyr episode of increased siliceous plankton abundance indicates enhanced nutrient levels between ~ 39.9 and 39.7 Ma. Throughout the Site 1051 record, abundance and accumulation rate fluctuations in neritic diatom taxa are similar to the trends observed in pelagic taxa, implying either similar controls on diatom production in the neritic and pelagic zones of the western North Atlantic or fluctuations in sea level and/or shelf accommodation on the North American continental margin to the west of Site 1051. These results, combined with published records based on multiple proxies, indicate a geographically diverse pattern of surface ocean primary production changes across the MECO. Notably, however, increased biosiliceous accumulation is recorded at both ODP Sites 1051 and 748 (Southern Ocean) in response to MECO warming. This may suggest that increased biosiliceous sediment accumulation, if indeed a widespread phenomenon, resulted from higher continental silicate weathering rates and an increase in silicic acid supply to the oceans over several 100 kyr during the MECO

The Epiphytic Genus Gambierdiscus (Dinophyceae) in the Kermadec Islands and Zealandia Regions of the Southwestern Pacific and the Associated Risk of Ciguatera Fish Poisoning

Species in the genus Gambierdiscus produce ciguatoxins (CTXs) and/or maitotoxins (MTXs), which may cause ciguatera fish poisoning (CFP) in humans if contaminated fish are consumed. Species of Gambierdiscus have previously been isolated from macroalgae at Rangitahua (Raoul Island and North Meyer Islands, northern Kermadec Islands), and the opportunity was taken to sample for Gambierdiscus at the more southerly Macauley Island during an expedition in 2016. Gambierdiscus cells were isolated, cultured, and DNA extracted and sequenced to determine the species present. Bulk cultures were tested for CTXs and MTXs by liquid chromatography-mass spectrometry (LC-MS/MS). The species isolated were G. australes, which produced MTX-1 (ranging from 3 to 36 pg/cell), and G. polynesiensis, which produced neither MTX-1 nor, unusually, any known CTXs. Isolates of both species produced putative MTX-3. The risk of fish, particularly herbivorous fish, causing CFP in the Zealandia and Kermadec Islands region is real, although in mainland New Zealand the risk is currently low. Both Gambierdiscus and Fukuyoa have been recorded in the sub-tropical northern region of New Zealand, and so the risk may increase with warming seas and shift in the distribution of Gambierdiscus species

Decision-analysis to guide recovery of the Po’ouli, a critically endangered Hawaiian honeycreeper

We used a probabilistic decision tree to help select among alternative recovery strategies for the Po‘ouli, a critically endangered forest bird endemic to the Hawaiian island of Maui. The Po‘ouli is one of the rarest birds in the world, with only three individuals known, and no breeding pairs. The most urgent conservation need for the species is to create a breeding pair and obtain eggs for captive propagation. Seven recovery strategies had been proposed, and there was disagreement among conservation workers about which strategy to pursue. In addition to lengthy discussions, a decision tree was introduced to provide an objective way of quantifying the chance of success under each alternative. All available information was used to attempt evaluation of each node in the decision tree. The overall chance of obtaining eggs was calculated by multiplying estimates at each node under each alternative. All options produced low estimates of potential success, but two options, removal of all birds to captivity and placement of the birds in a field aviary in an accessible location, produced similar estimates of success. The US Fish and Wildlife Service and the Hawaii Division of Forestry and Wildlife eventually agreed that removal to captivity was the preferred alternative because it could be implemented quickly, which was important considering the advanced age of the birds, and would make it easier to provide veterinary care and ensure their safety from predators, severe weather, and vandals. Decision trees and other structured models should not be relied on exclusively, but they can provide an objective method of helping to make difficult conservation decisions and provide a record of complex thought processes used in reaching a determination. The case of the Po‘ouli may serve as a template for navigation towards a decision to recover other species of extreme rarity