Integrated diagnostic pathway for patients referred with suspected OSA: a model for collaboration across the primary-secondary care interface

BACKGROUND: Obstructive sleep apnoea (OSA) presents a major healthcare challenge with current UK data suggesting that only 22% of individuals have been diagnosed and treated. Promoting awareness and improving access to diagnostics are fundamental in addressing these missing cases and the recognised complications associated with untreated OSA. Diagnosis usually occurs in secondary care with data from our trust revealing long wait times to undertake tests, reach a diagnosis and start treatment. This places a considerable time and emotional burden on the patient and a financial and logistical burden on the hospital. METHODS: We introduced an integrated community-based pathway for the diagnosis of OSA. This comprised a monthly clinic run from within a local general practice (GP) supported by a 'virtual multidisciplinary team' run by the hospital specialist team. Prospective collection of process, outcome and patient satisfaction data was compared with traditional hospital-based pathway data collected retrospectively. SETTING: A central London teaching hospital and GPs within a local commissioning neighbourhood. RESULTS: Between January 2018 and February 2019, 70 were patients referred and managed along the community pathway. Compared with the hospital pathway, data demonstrated a significant reduction in the time taken: from referral to perform a sleep test (29 vs 181 days, p<0.0001), to make a diagnosis (40 vs 230 days, p<0.0001) and commence treatment (127 vs 267, p<0.0001). Patient satisfaction in the community pathway was higher across all domains (p<0.05), fewer hospital outpatient appointments were required and cost estimates suggested an overall saving of up to £290 could be achieved for each patient. CONCLUSION: An integrated community-based pathway results in more timely diagnosis of OSA within a local setting while maintaining specialist input from the hospital team. It is favoured by patients and can reduce unnecessary appointments in secondary care

Current treatment strategies in managing side effects associated with domiciliary positive airway pressure (PAP) therapy for patients with sleep disordered breathing: A systematic review and meta-analysis

Sleep disordered breathing is commonly treated with positive airway pressure therapy. Positive airway pressure therapy is delivered via a tight-fitting mask with common side effects including: leak, ineffective treatment, residual sleep disordered breathing, eye irritation, nasal congestion, pressure ulcers and poor concordance with therapy. This systematic review and meta-analysis aimed to identify the effectiveness of current treatment strategies for managing side effects associated with positive airway pressure therapy. Five databases were searched and 10,809 articles were screened, with 36 articles included in the review. Studies investigated: dressings, nasal spray/douche, chin straps, heated humidification and interfaces. No intervention either improved or detrimentally affected: positive airway pressure concordance, Epworth Sleepiness Score, residual apnoea hypopnea index or interface leak. The review was limited by study heterogeneity, particularly for outcome measures. Additionally, patient demographics were not reported, making it difficult to apply the findings to a broad clinical population. This review highlights the paucity of evidence supporting treatment strategies to manage side effects of positive airway pressure therapy

Non-volatile voltage control of in-plane and out-of-plane magnetization in polycrystalline Ni films on ferroelectric PMN-PT (001)pcsubstrates

We identify room-temperature converse magnetoelectric effects (CMEs) that are non-volatile by using a single-crystal substrate of PMN-PT (001)pc (pc denotes pseudocubic) to impart voltage-driven strain to a polycrystalline film of Ni. An appropriate magnetic-field history enhances the magnetoelectric coefficient to a near-record peak of ∼10-6 s m-1 and permits electrically driven magnetization reversal of substantial net magnetization. In zero magnetic field, electrically driven ferroelectric domain switching produces large changes of in-plane magnetization that are non-volatile. Microscopically, these changes are accompanied by the creation and destruction of magnetic stripe domains, implying the electrical control of perpendicular magnetic anisotropy. Moreover, the stripe direction can be rotated by a magnetic field or an electric field, the latter yielding the first example of electrically driven rotatable magnetic anisotropy. The observed CMEs are associated with repeatable ferroelectric domain switching that yields a memory effect. This memory effect is well known for PMN-PT (110)pc but not PMN-PT (001)pc. Given that close control of the applied field is not required as for PMN-PT (110)pc, this memory effect could lead the way to magnetoelectric memories based on PMN-PT (001)pc membranes that switch at low voltage

Spin-splitting in p-type Ge devices

Compressively strained Ge quantum well devices have a spin-splitting in applied magnetic field that is entirely consistent with a Zeeman effect in the heavy hole valence band. The spin orientation is determined by the biaxial strain in the quantum well with the relaxed SiGe buffer layers and is quantized in the growth direction perpendicular to the conducting channel. The measured spin-splitting in the resistivity ρxx agrees with the predictions of the Zeeman Hamiltonian where the Shubnikov-deHaas effect exhibits a loss of even filling factor minima in the resistivity ρxx with hole depletion from a gate field, increasing disorder or increasing temperature. There is no measurable Rashba spin-orbit coupling irrespective of the structural inversion asymmetry of the confining potential in low p-doped or undoped Ge quantum wells from a density of 6 × 1010 cm−2 in depletion mode to 1.7 × 1011 cm−2 in enhancement

Ultra-low phase noise squeezed vacuum source for gravitational wave detectors

Squeezed states of light are a valuable resource for reducing quantum noise in precision measurements. Injection of squeezed vacuum states has emerged as an important technique for reducing quantum shot noise, which is a fundamental limitation to the sensitivity of interferometric gravitational wave detectors. Realizing the most benefit from squeezed-state injection requires lowering optical losses and also minimizing squeezed quadrature fluctuations—or phase noise—to ensure that the large noise in the anti-squeezed quadrature does not contaminate the measurement quadrature. Here, we present an audio band squeezed vacuum source with 1.3+0.7−0.5 mrad of phase noise. This is a nearly tenfold improvement over previously reported measurements, improving prospects for squeezing enhancements in current and future gravitational wave detectors

Implications of Inflammatory Bowel Disease for reconstructive surgery in non-malignant urinary tract dysfunction:an International Continence Society working group report

Potential consequences of inflammatory bowel disease (IBD) need evaluation for patients considering urinary tract reconstruction for benign disease. A working group was formed by the International Continence Society, which considered urinary tract reconstruction in IBD.Methods Nominal group technique was used to derive consensus. Principal aspects of IBD assessment and surgery decision-making were agreed. A questionnaire was used to facilitate the generation of statements by a core focus group of experts, which were modified and ratified by the wider working group. This was followed by final voting by the full working group.Results General considerations included identification importance of the specialist IBD multi-disciplinary team. Peri-operative considerations recommended avoiding pre-operative fasting from midnight and using an enhanced recovery after surgery (ERAS) protocol. Selection of bowel segment, pre-operative optimisation and post-operative issues were considered for both Ulcerative colitis (UC) and Crohn’s disease. UC is not an absolute contraindication to urinary tract reconstruction using small or large bowel. Elective reconstructive surgery should wait at least three months following resolution of any acute UC flare-up to correct all abnormalities. Crohn’s disease is a high-risk disease for urinary tract reconstruction, even if in remission. In Crohn’s, reconstructive surgical options are limited by the location and extent of gastrointestinal segment(s) affected and the phenotype of disease.Conclusion The consensus opinion indicates that urinary tract reconstruction using bowel segments is feasible in carefully selected and optimised patients with IBD lacking alternative management options, provided there is access to appropriate multidisciplinary skills. UC is relatively low risk for surgical procedures, whereas Crohn’s has considerably increased risk of morbidity. The potential risks must be properly discussed with patients considering reconstructive urological procedures. Outcomes should be carefully monitored and published to identify the safety and efficacy of reconstructive surgery in IBD, including full description of the disease status

Electronic and magnetic characterization of epitaxial CrBr3_3 monolayers

The ability to imprint a given material property to another through proximity effect in layered two-dimensional materials has opened the way to the creation of designer materials. Here, we use molecular-beam epitaxy (MBE) for a direct synthesis of a superconductor-magnet hybrid heterostructure by combining superconducting niobium diselenide (NbSe$_2$) with the monolayer ferromagnetic chromium tribromide (CrBr$_3$). Using different characterization techniques and density-functional theory (DFT) calculations, we have confirmed that the CrBr$_3$ monolayer retains its ferromagnetic ordering with a magnetocrystalline anisotropy favoring an out-of-plane spin orientation. Low-temperature scanning tunneling microscopy (STM) measurements show a slight reduction of the superconducting gap of NbSe$_2$ and the formation of a vortex lattice on the CrBr$_3$ layer in experiments under an external magnetic field. Our results contribute to the broader framework of exploiting proximity effects to realize novel phenomena in 2D heterostructures

Voltage-driven displacement of magnetic vortex cores

Magnetic vortex cores in polycrystalline Ni discs underwent non-volatile displacements due to voltage-driven ferroelectric domain switching in single-crystal BaTiO3. This behaviour was observed using photoemission electron microscopy to image both the ferromagnetism and ferroelectricity, while varying in-plane sample orientation. The resulting vector maps of disc magnetization match well with micromagnetic simulations, which show that the vortex core is translated by the transit of a ferroelectric domain wall, and thus the inhomogeneous strain with which it is associated. The non-volatility is attributed to pinning inside the discs. Voltage-driven displacement of magnetic vortex cores is novel, and opens the way for studying voltage-driven vortex dynamics

Sensitivity and performance of the Advanced LIGO detectors in the third observing run

On April 1st, 2019, the Advanced Laser Interferometer Gravitational-Wave Observatory (aLIGO), joined by the Advanced Virgo detector, began the third observing run, a year-long dedicated search for gravitational radiation. The LIGO detectors have achieved a higher duty cycle and greater sensitivity to gravitational waves than ever before, with LIGO Hanford achieving angle-averaged sensitivity to binary neutron star coalescences to a distance of 111 Mpc, and LIGO Livingston to 134 Mpc with duty factors of 74.6% and 77.0% respectively. The improvement in sensitivity and stability is a result of several upgrades to the detectors, including doubled intracavity power, the addition of an in-vacuum optical parametric oscillator for squeezed-light injection, replacement of core optics and end reaction masses, and installation of acoustic mode dampers. This paper explores the purposes behind these upgrades, and explains to the best of our knowledge the noise currently limiting the sensitivity of each detector. © 2020 authors. Published by the American Physical Society

Mechanisms for reducing low back pain: a mediation analysis of a multifaceted intervention in workers in elderly care

Purpose A multifaceted workplace intervention consisting of participatory ergonomics, physical training, and cognitive–behavioural training (CBT) has shown effectiveness for reducing low back pain (LBP). However, the mechanisms of action underlying these intervention components are not well understood. Methods This was a mediation analysis of a cluster-randomised controlled trial of a multifaceted intervention in 420 workers in elderly care. Mediation analysis was carried out via structural equation modelling. Potential mediators investigated were: fear-avoidance beliefs, perceived muscle strength, use of assistive devices at work and perceived physical exertion at work. LBP outcomes assessed were: days with LBP, LBP intensity and days with bothersome LBP. Results There were no significant indirect effects of the intervention on LBP outcomes. There were significant effects of the intervention on both fear-avoidance measures [β = − 0.63, 95% CI (1.23, 0.03); β = − 1.03, 95% CI (− 1.70, − 0.34)] and the use of assistive devices [β = − 0.55, 95% CI (− 1.04, − 0.05)], but not on perceived muscle strength [β = − 0.18, 95% CI (− 0.50, 0.13)] or physical exertion [β = − 0.05, 95% CI (− 0.40, 0.31)]. The only potential mediator with a significant effect on LBP outcomes was physical exertion, which had a significant effect on LBP intensity [β = 0.14, 95% CI (0.04, 0.23)]. Conclusions A multifaceted intervention consisting of participatory ergonomics, physical training, and CBT was able to decrease fear-avoidance beliefs and increase use of assistive devices in the workplace. However, these changes did not explain the effect of any of the intervention components on days with LBP, LBP intensity and days with bothersome LBP