Minimising barriers to dental care in older people

<p>Abstract</p> <p>Background</p> <p>Older people are increasingly retaining their natural teeth but at higher risk of oral disease with resultant impact on their quality of life. Socially deprived people are more at risk of oral disease and yet less likely to take up care. Health organisations in England and Wales are exploring new ways to commission and provide dental care services in general and for vulnerable groups in particular. This study was undertaken to investigate barriers to dental care perceived by older people in socially deprived inner city area where uptake of care was low and identify methods for minimising barriers in older people in support of oral health.</p> <p>Methods</p> <p>A qualitative dual-methodological approach, utilising both focus groups and individual interviews, was used in this research. Participants, older people and carers of older people, were recruited using purposive sampling through day centres and community groups in the inner city boroughs of Lambeth, Southwark and Lewisham in South London. A topic guide was utilised to guide qualitative data collection. Informants' views were recorded on tape and in field notes. The data were transcribed and analysed using Framework Methodology.</p> <p>Results</p> <p>Thirty-nine older people and/or their carers participated in focus groups. Active barriers to dental care in older people fell into five main categories: cost, fear, availability, accessibility and characteristics of the dentist. Lack of perception of a need for dental care was a common 'passive barrier' amongst denture wearers in particular. The cost of dental treatment, fear of care and perceived availability of dental services emerged to influence significantly dental attendance. Minimising barriers involves three levels of action to be taken: individual actions (such as persistence in finding available care following identification of need), system changes (including reducing costs, improving information, ensuring appropriate timing and location of care, and good patient management) and societal issues (such as reducing isolation and loneliness). Older people appeared to place greater significance on system and societal change than personal action.</p> <p>Conclusion</p> <p>Older people living within the community in an inner city area where NHS dental care is available face barriers to dental care. Improving access to care involves actions at individual, societal and system level. The latter includes appropriate management of older people by clinicians, policy change to address NHS charges; consideration of when, where and how dental care is provided; and clear information for older people and their carers on available local dental services, dental charges and care pathways.</p

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Optimal stomatal behaviour around the world

© 2015 Macmillan Publishers Limited. All rights reserved. Stomatal conductance (g s) is a key land-surface attribute as it links transpiration, the dominant component of global land evapotranspiration, and photosynthesis, the driving force of the global carbon cycle. Despite the pivotal role of g s in predictions of global water and carbon cycle changes, a global-scale database and an associated globally applicable model of g s that allow predictions of stomatal behaviour are lacking. Here, we present a database of globally distributed g s obtained in the field for a wide range of plant functional types (PFTs) and biomes. We find that stomatal behaviour differs among PFTs according to their marginal carbon cost of water use, as predicted by the theory underpinning the optimal stomatal model and the leaf and wood economics spectrum. We also demonstrate a global relationship with climate. These findings provide a robust theoretical framework for understanding and predicting the behaviour of g s across biomes and across PFTs that can be applied to regional, continental and global-scale modelling of ecosystem productivity, energy balance and ecohydrological processes in a future changing climate

Optimal stomatal behaviour around the world

This is the author accepted manuscript. The final version is available from Springer Nature via the DOI in this recordStomatal conductance (g s) is a key land-surface attribute as it links transpiration, the dominant component of global land evapotranspiration, and photosynthesis, the driving force of the global carbon cycle. Despite the pivotal role of g s in predictions of global water and carbon cycle changes, a global-scale database and an associated globally applicable model of g s that allow predictions of stomatal behaviour are lacking. Here, we present a database of globally distributed g s obtained in the field for a wide range of plant functional types (PFTs) and biomes. We find that stomatal behaviour differs among PFTs according to their marginal carbon cost of water use, as predicted by the theory underpinning the optimal stomatal model and the leaf and wood economics spectrum. We also demonstrate a global relationship with climate. These findings provide a robust theoretical framework for understanding and predicting the behaviour of g s across biomes and across PFTs that can be applied to regional, continental and global-scale modelling of ecosystem productivity, energy balance and ecohydrological processes in a future changing climate.This research was supported by the Australian Research Council (ARC MIA Discovery Project 1433500-2012-14). A.R. was financially supported in part by The Next-Generation Ecosystem Experiments (NGEE-Arctic) project, which is supported by the Office of Biological and Environmental Research in the Department of Energy, Office of Science, and through the United States Department of Energy contract No. DE-AC02-98CH10886 to Brookhaven National Laboratory. M.O.d.B. acknowledges that the Brassica data were obtained within a research project financed by the Belgian Science Policy (OFFQ, contract number SD/AF/02) and coordinated by K. Vandermeiren at the Open-Top Chamber research facilities of CODA-CERVA (Tervuren, Belgium)

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Efeito da suplementação com ácido linoléico conjugado e do treinamento em natação sobre a composição corporal e os parâmetros bioquímicos de ratos Wistar em crescimento Effect of conjugated linoleic acid supplementation and swimming training on the body composition and biochemical parameters of Wistar pups

OBJETIVO: Avaliar os efeitos da suplementação com ácido linoléico conjugado, associada ao treinamento moderado em natação, sobre a composição corporal, o consumo e a eficiência alimentar, a glicemia, o perfil lipídico e o glicogênio muscular e hepático de ratos Wistar. MÉTODOS: Ratos Wistar (30 dias) foram divididos em: sedentário, sedentário suplementado, treinado e treinado suplementado. Permaneceram em gaiolas individuais com comida e água ad libitum, temperatura de 23ºC (com variação de1ºC) e ciclo claro-escuro de 12 horas, durante 8 semanas. A sessão de natação durou 1 hora e foi realizada três vezes/semana, bem como a suplementação com ácido linoléico conjugado a 2%. Após sacrifício, o plasma, os tecidos adiposos brancos e o marrom, o músculo gastrocnêmio e o fígado foram coletados e pesados. RESULTADOS: A suplementação per se não promoveu modificação na ingestão alimentar e na massa corporal dos animais. Houve aumento na glicemia de jejum (p<0,05), nas lipoproteínas de alta densidade (p<0,05), no colesterol total (p<0,05) e redução dos triacilgliceróis. A suplementação associada ao treinamento reduziu a massa corporal (p<0,05) e aumentou o peso relativo do tecido adiposo, do fígado e a glicemia de jejum. CONCLUSÃO: A suplementação com ácido linoléico conjugado associada à prática de exercício físico parece ter influência no balanço energético, mas, por outro lado, o aumento no peso do fígado indica que a ingestão deste ácido graxo pode ter efeitos indesejáveis, aumentando as chances de desenvolvimento do fígado gorduroso. Estes achados apontam perspectivas para novos estudos envolvendo análises histológicas do fígado, expressão gênica de enzimas chaves do metabolismo lipídico e de carboidratos, associados ou não a diferentes protocolos de treinamento físico.<br>OBJECTIVE: The objective of this study was to evaluate the effects of conjugated linoleic acid supplementation associated with moderate swimming training on body composition, food efficiency and consumption, blood glucose, lipid profile, and muscle and liver glycogen of Wistar rats. METHODS: Thirty-day old Wistar rats were divided into the following groups: inactive, inactive with 2% conjugated linoleic acid supplementation, active, and active with 2% conjugated linoleic acid supplementation. They remained in individual cages with food and water ad libitum, temperature of 23±1ºC and a light and dark cycle of 12 hours for 8 weeks. The active groups swam for one hour three times per week. The animals were killed and the plasma, white and brown fat tissues, gastrocnemius muscle and liver were collected and weighted. RESULTS: Supplementation per se did not promote food intake or body weight changes in the animals. Fasting glucose (p<0.05) and high density lipoproteins (HDL, p<0.05) increased and triacylglycerols decreased. Supplementation associated with activity decreased body mass (p<0.05) and increased the relative weight of fat tissues, liver and fasting glucose. CONCLUSION: Conjugated linoleic acid supplementation associated with physical activity seems to influence energy balance. On the other hand, the increased liver weight indicates that intake of this fatty acid may have undesirable side-effects, increasing the chances of developing fatty liver. This new perspective makes way for new studies including histological analyses of the liver and gene expression of key enzymes from the lipid and carbohydrate metabolism, associated or not with different physical training protocols