Caregivers’ interactions with health care services: mediator of stress or added strain? Experiences and perceptions of informal caregivers of people with dementia: a qualitative study

Background: There are an estimated 46.8 million people worldwide living with dementia in 2015, being cared for usually by family members or friends (informal caregivers). The challenges faced by informal caregivers often lead to increased levels of stress, burden and risk of care-recipient institutionalisation. Aim: The overarching aim of this study was to explore the experiences and perceptions of informal caregivers of people with dementia when interacting with the health care system, and whether the support received acted as a mediator of caregiver stress. The secondary aim was to investigate healthcare professionals’ views and current practice regarding people with dementia and their interactions with informal caregivers. Method: We employed a qualitative research design, using focus groups and one face-to-face interview with a purposive sample of informal caregivers and healthcare professionals (HCPs) in Lincolnshire, UK. Data were collected between March and July 2015. We used the stress-process model of stress in caregivers as a theoretical framework. Results: We interviewed 18 caregivers and 17 HCPs. Five themes, mapped to the stress-process in caregivers’ model, captured the main challenges faced by caregivers and the type of support they wanted from health care services. Primary stressors included the challenge of diagnosing dementia; caregivers’ needs and expectations of an in-depth knowledge and understanding of dementia from HCPs; and need for carer education. Secondary role strain included lack of support and mismatch of communication and expectations. Caregiver involvement in monitoring care and disease was a potential mediator tool. Conclusions: Fragmentation of dementia care services, lack of training for HCPs and the dearth of information for caregivers means health care services are only partially fulfilling a support role. In turn, lack of support may be intensifying caregiver stress leading to worsening in their health and well-being; thus, potentially increasing the risk of institutionalisation of their care-recipient

Spatially resolved spectroscopy of planetary nebulae and their halos I. Five galactic disk objects

Strong mass loss off stars at the tip of the asymptotic giant branch (AGB) profoundly affects properties of these stars and their surroundings, including the subsequent planetary nebula (PN) stage. With this study we wanted to determine physical properties of mass loss by studying weakly emitting halos, focusing on objects in the galactic disk. Halos surround the, up to several thousand times, brighter central regions of PNe. Young halos, specifically, still contain information of the preceeding final mass loss stage on the AGB. In the observations we used the method of integral field spectroscopy with the PMAS instrument. This is the first committed study of halos of PNe that uses this technique. We improved our data analysis by a number of steps. In a study of the influence of scattered light we found that a moderate fraction of intensities in the inner halo originate in adjacent regions. As we combine line intensities of distant wavelengths, and because radial intensity gradients are steep, we corrected for effects of differential atmospheric refraction. In order to increase the signal-to-noise of weak emission lines we introduced a dedicated method to bin spectra of individual spatial elements. We also developed a general technique to subtract telluric lines - without using separate sky exposures. By these steps we avoided introducing errors of several thousand Kelvin to our temperature measurements in the halo. For IC3568 we detected a halo. For M2-2 we found a halo radius that is 2.5 times larger... (abridged)Comment: 27 pages, 29 figures, A&A (in press), Abridged abstract, Corrected and clarified various minor issues; the section on scattered light is significantly clarifie

The Fine Structure Lines of Hydrogen in HII Regions

The 2s_{1/2} state of hydrogen is metastable and overpopulated in HII regions. In addition, the 2p states may be pumped by ambient Lyman-alpha radiation. Fine structure transitions between these states may be observable in HII regions at 1.1 GHz (2s_{1/2}-2p_{1/2}) and/or 9.9 GHz (2s_{1/2}-2p_{3/2}), although the details of absorption versus emission are determined by the relative populations of the 2s and 2p states. The n=2 level populations are solved with a parameterization that allows for Lyman-alpha pumping of the 2p states. The density of Lyman-alpha photons is set by their creation rate, easily determined from the recombination rate, and their removal rate. Here we suggest that the dominant removal mechanism of Lyman-alpha radiation in HII regions is absorption by dust. This circumvents the need to solve the Lyman-alpha transfer problem, and provides an upper limit to the rate at which the 2p states are populated by Lyman-alpha photons. In virtually all cases of interest, the 2p states are predominantly populated by recombination, rather than Lyman-alpha pumping. We then solve the radiative transfer problem for the fine structure lines in the presence of free-free radiation. In the likely absence of Lyman-alpha pumping, the 2s_{1/2}-2p_{1/2} lines will appear in stimulated emission and the 2s_{1/2}-2p_{3/2} lines in absorption. Searching for the 9.9 GHz lines in high emission measure HII regions offers the best prospects for detection. The lines are predicted to be weak; in the best cases, line-to-continuum ratios of several tenths of a percent might be expected with line strengths of tens to a hundred mK with the Green Bank Telescope.Comment: 18 pages, 2 figures, accepted by ApJ, references added, typos correcte

‘Caveat emptor’: the cautionary tale of endocarditis and the potential pitfalls of clinical coding data—an electronic health records study

Background Diagnostic codes from electronic health records are widely used to assess patterns of disease. Infective endocarditis is an uncommon but serious infection, with objective diagnostic criteria. Electronic health records have been used to explore the impact of changing guidance on antibiotic prophylaxis for dental procedures on incidence, but limited data on the accuracy of the diagnostic codes exists. Endocarditis was used as a clinically relevant case study to investigate the relationship between clinical cases and diagnostic codes, to understand discrepancies and to improve design of future studies. Methods Electronic health record data from two UK tertiary care centres were linked with data from a prospectively collected clinical endocarditis service database (Leeds Teaching Hospital) or retrospective clinical audit and microbiology laboratory blood culture results (Oxford University Hospitals Trust). The relationship between diagnostic codes for endocarditis and confirmed clinical cases according to the objective Duke criteria was assessed, and impact on estimations of disease incidence and trends. Results In Leeds 2006–2016, 738/1681(44%) admissions containing any endocarditis code represented a definite/possible case, whilst 263/1001(24%) definite/possible endocarditis cases had no endocarditis code assigned. In Oxford 2010–2016, 307/552(56%) reviewed endocarditis-coded admissions represented a clinical case. Diagnostic codes used by most endocarditis studies had good positive predictive value (PPV) but low sensitivity (e.g. I33-primary 82% and 43% respectively); one (I38-secondary) had PPV under 6%. Estimating endocarditis incidence using raw admission data overestimated incidence trends twofold. Removing records with non-specific codes, very short stays and readmissions improved predictive ability. Estimating incidence of streptococcal endocarditis using secondary codes also overestimated increases in incidence over time. Reasons for discrepancies included changes in coding behaviour over time, and coding guidance allowing assignment of a code mentioning ‘endocarditis’ where endocarditis was never mentioned in the clinical notes. Conclusions Commonly used diagnostic codes in studies of endocarditis had good predictive ability. Other apparently plausible codes were poorly predictive. Use of diagnostic codes without examining sensitivity and predictive ability can give inaccurate estimations of incidence and trends. Similar considerations may apply to other diseases. Health record studies require validation of diagnostic codes and careful data curation to minimise risk of serious errors