The drive to discharge older people with frailty at the end of life from community hospital. A constructivist grounded theory study

There has been an increasing acknowledgement in recent years of the importance of recognising frailty as a condition that leaves older people vulnerable to dramatic, sudden changes in health triggered by seemingly small events such as a minor infection or a change in medication or environment. Older people with frailty are those who are at highest risk of adverse outcomes such as falls, disability, admission to hospital, and the need for long-term care. The approach to managing frailty is often with an emphasis on staying well, even though, due to an increase in conditions such as dementia, heart disease, stroke and arthritis, Seymour (2017) suggests, 'end-of-life care' is 'care of older people'. Meanwhile, discharge from hospital continues to be contentious, with overstretched acute hospitals juxtaposed with community services that struggle to keep up with the demand of those being discharged. Studies that look at the combination of frailty, end of life and hospital discharge are limited. Furthermore, previous studies looking at these areas focus on perceptions of health professionals or patients and informal carers, but not on stakeholders as a whole. This qualitative study explored the experiences of stakeholders involved in the discharge from hospital of an older person living with frailty who is nearing the end of life. This included the patient, their informal carer(s), community hospital staff, community health professionals and care home managers. A constructivist grounded theory methodology was used, and semi-structured interviews were conducted with 55 participants. The interview data were analysed and interpreted using the constant comparative method and situational analysis. The study findings provided valuable insight into the experience of older people living with frailty approaching the end of life, their informal carers and health professionals involved in the discharge from community hospital. The study added to the knowledge of the discharge process for all stakeholders. The core category of 'the drive to discharge conveyor belt' was produced from the data analysis alongside four dynamic, interrelated conceptual categories and the subcategories within these. These conceptual categories were: 'resource limitations', 'mismatch in expectations', 'choice and control' and 'carer burden'. The study captured how the discharge conveyor belt is caused by and causes resource limitation, mismatch in expectations between health professionals, patients and carers and how concepts of choice and control influence decision making. These concepts combine to increase the carer burden. The carer was found to be 'intrinsic' to the discharge and facilitating the older person living in their place of choice. Intersectionality was used to interrogate how the drive to discharge intersects with older people and their informal carers to create inequitable outcomes, and to generate recommendations

The rhetoric and reality of choice and autonomy when older people are discharged from community hospital at the end-of-Life in England: A constructivist grounded theory study

There has been an increasing acknowledgement in the UK of the importance of recognising frailty as a condition that leaves older people vulnerable to dramatic, sudden changes in health triggered by seemingly small events. In policy, the approach to managing frailty is often an emphasis on staying well with limited consideration to frailty as an end-of-life phase. Meanwhile, discharge from hospital continues to be complex. Overstretched acute hospitals are juxtaposed with community and social services that struggle to keep up with the demand of those being discharged and the labelling of older people as “bed blockers” at the centre of delayed discharges. This paper reports a study underpinned by constructivist grounded theory methodology, with the aim of exploring the experiences and perceptions of stakeholders. Semistructured interviews were conducted with 57 participants including patients, their informal carer(s), community hospital staff, community health professionals, and care home managers. The core category of “the drive to discharge conveyor belt” was derived from data analysis. A significant finding of this study was that of the carer, their burden, and their intrinsic role in facilitating discharge, filling in gaps in services, coordinating services, and enabling the patient to stay at home, with little consideration of their choices or autonomy. The “drive to discharge” impacts older people, their informal carers, and health professional. This study suggests how they may be supported, through an ethical lens

Can early years professionals determine which preschoolers have comprehension delays? A comparison of two screening tools

Language comprehension delays in pre-schoolers are predictive of difficulties in a range of developmental domains. In England, early years setting staff are required to assess the language comprehension of two-year-olds in their care. Many use a format based on the Early Years Foundation Stage My Unique Child (EYFS:UCCS ) in which the child’s language comprehension is assigned to an age band based on written guidance. Seventy 2½-3-year-olds were assessed on the comprehension component of the Preschool Language Scale (PLS) by psychology graduates. Early years practitioners assessed language comprehension in the same children using the EYFS:UCCS and the WellComm which involves some direct testing. The EYFS:UCCS had poor sensitivity and specificity and the understanding section did not correlate with the PLS. The WellComm had good-acceptable levels of sensitivity and specificity and significantly correlated with the PLS. Early years setting staff can accurately assess the language comprehension of two-year-olds if provided with a tool which gives specific instructions on administration, but current frequently used procedures (EYFS:UCCS) are not fit for this purpose

Working with bilingual children at risk of developmental language disorder:adapting assessment and intervention for the nursery-aged bilingual child

A proportion of all children (7.58%: RCSLT) have significant difficulty acquiring language, irrespective of whether this applies to their first and only language or to two or more languages acquired in a multilingual setting. These children have developmental language disorder (DLD) and once identified are supported in school by speech & language therapists working with SENDCOs and other school staff. The majority are slow to develop language in the preschool years and identification and intervention at that point is crucial for later education including literacy. This poses a problem for professionals if the child is bilingual; distinguishing overall language delay from lack of familiarity with the majority language and providing intervention in the home language are both problematic. This work is part of a larger project (LIVELY) investigating the effectiveness of an early language programme for 3-4 year olds who are at risk for DLD. The programme focuses on early word combinations and sentences of increasing complexity. We are conducting a number of case studies with children who are acquiring a home language and expected to learn English. For these children, the programme will be conducted in their home language. This involves adaptation of both language assessment and intervention material to this language, with the possibility of remote working with the child if dictated by the pandemic situation. In this presentation we describe the strategies used to make these adaptations to Polish and to Mirpuri (Pakistani Heritage language), both of which are spoken widely in the UK. While sentence structure differs across languages, the focus is on the unique events that can be communicated through early sentences, universal to all linguistic contexts. Specific issues that we have encountered in developing these adaptations will also be discussed. Language Intervention in the Early Years (LIVELY): https://research.ncl.ac.uk/lively/aboutlively/ Royal College of Speech & Language Therapists (RCSLT): https://www.rcslt.org

Antibiotic prophylaxis in anterior skull‐base surgery: a survey of the North American Skull Base Society

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151867/1/alr22396.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151867/2/alr22396_am.pd

EM-mosaic detects mosaic point mutations that contribute to congenital heart disease.

BackgroundThe contribution of somatic mosaicism, or genetic mutations arising after oocyte fertilization, to congenital heart disease (CHD) is not well understood. Further, the relationship between mosaicism in blood and cardiovascular tissue has not been determined.MethodsWe developed a new computational method, EM-mosaic (Expectation-Maximization-based detection of mosaicism), to analyze mosaicism in exome sequences derived primarily from blood DNA of 2530 CHD proband-parent trios. To optimize this method, we measured mosaic detection power as a function of sequencing depth. In parallel, we analyzed our cohort using MosaicHunter, a Bayesian genotyping algorithm-based mosaic detection tool, and compared the two methods. The accuracy of these mosaic variant detection algorithms was assessed using an independent resequencing method. We then applied both methods to detect mosaicism in cardiac tissue-derived exome sequences of 66 participants for which matched blood and heart tissue was available.ResultsEM-mosaic detected 326 mosaic mutations in blood and/or cardiac tissue DNA. Of the 309 detected in blood DNA, 85/97 (88%) tested were independently confirmed, while 7/17 (41%) candidates of 17 detected in cardiac tissue were confirmed. MosaicHunter detected an additional 64 mosaics, of which 23/46 (50%) among 58 candidates from blood and 4/6 (67%) of 6 candidates from cardiac tissue confirmed. Twenty-five mosaic variants altered CHD-risk genes, affecting 1% of our cohort. Of these 25, 22/22 candidates tested were confirmed. Variants predicted as damaging had higher variant allele fraction than benign variants, suggesting a role in CHD. The estimated true frequency of mosaic variants above 10% mosaicism was 0.14/person in blood and 0.21/person in cardiac tissue. Analysis of 66 individuals with matched cardiac tissue available revealed both tissue-specific and shared mosaicism, with shared mosaics generally having higher allele fraction.ConclusionsWe estimate that ~ 1% of CHD probands have a mosaic variant detectable in blood that could contribute to cardiac malformations, particularly those damaging variants with relatively higher allele fraction. Although blood is a readily available DNA source, cardiac tissues analyzed contributed ~ 5% of somatic mosaic variants identified, indicating the value of tissue mosaicism analyses