Developing and implementing an integrated delirium prevention system of care:a theory driven, participatory research study

Background: Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery. Methods: We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data. Results: Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier. Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices. Conclusions: Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly

Comparison between dopaminergic agents and physical exercise as treatment for periodic limb movements in patients with spinal cord injury

Study design: Randomized controlled trial of physical exercise and dopaminergic agonist in persons with spinal cord injury and periodic leg movement (PLM).Objective: the objective of the present study was to compare the effectiveness of physical exercise and of a dopaminergic agonist in reducing the frequency of PLM.Setting: Centro de Estudos em Psicobiologia e Exercicio. Universidade Federal de São Paulo, Brazil.Methods: A total of 13 volunteers (mean age: 31.6 +/- 8.3 years) received L-DOPA ( 200 mg) and benserazide ( 50 mg) 1 h before sleeping time for 30 days and were then submitted to a physical exercise program on a manual bicycle ergometer for 45 days ( 3 times a week).Results: Both L-DOPA administration (35.11 - 19.87 PLM/h, P<0.03) and physical exercise (35.11 - 18.53 PLM/h, P<0.012) significantly reduced PLM; however, no significant difference was observed between the two types of treatment.Conclusions: the two types of treatment were found to be effective in the reduction of PLM; however, physical exercise is indicated as the first treatment approach, while dopaminergic agonists or other drugs should only be recommended for patients who do not respond to this type of treatment.UNIFESP, Dept Psychobiol, BR-04020060 São Paulo, BrazilUNIFESP, Dept Psychobiol, BR-04020060 São Paulo, BrazilWeb of Scienc

Observation of completely destructive quantum interference between interacting resonances in molecular predissociation

Predissociating resonances were observed for destructive interference in a region between the resonances. Multiphoton ionization spectroscopy which was enhanced by resonance was used for probing single rotational levels of O2 in case of double resonance technique. Double resonance technique resulted in the elimination of overlapping rotational structure

Incomplete functional recovery after delirium in elderly people: a prospective cohort study

BACKGROUND: Delirium often has a poor outcome, but why some people have incomplete recovery is not well understood. Our objective was to identify factors associated with short-term (by discharge) and long-term (by 6 month) incomplete recovery of function following delirium. METHODS: In a prospective cohort study of elderly patients with delirium seen by geriatric medicine services, function was assessed at baseline, at hospital discharge and at six months. RESULTS: Of 77 patients, vital and functional status at 6 months was known for 71, of whom 21 (30%) had died. Incomplete functional recovery, defined as ≥10 point decline in the Barthel Index, compared to pre-morbid status, was present in 27 (54%) of the 50 survivors. Factors associated with death or loss of function at hospital discharge were frailty, absence of agitation (hypoactive delirium), a cardiac cause and poor recognition of delirium by the treating service. Frailty, causes other than medications, and poor recognition of delirium by the treating service were associated with death or poor functional recovery at 6 months. CONCLUSION: Pre-existing frailty, cardiac cause of delirium, and poor early recognition by treating physicians are associated with worse outcomes. Many physicians view the adverse outcomes of delirium as intractable. While in some measure this might be true, more skilled care is a potential remedy within their grasp

Reticular synthesis and the design of new materials

The long-standing challenge of designing and constructing new crystalline solid-state materials from molecular building blocks is just beginning to be addressed with success. A conceptual approach that requires the use of secondary building units to direct the assembly of ordered frameworks epitomizes this process: we call this approach reticular synthesis. This chemistry has yielded materials designed to have predetermined structures, compositions and properties. In particular, highly porous frameworks held together by strong metal-oxygen-carbon bonds and with exceptionally large surface area and capacity for gas storage have been prepared and their pore metrics systematically varied and functionalized.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/62718/1/nature01650.pd

Use of neuroleptics in a general hospital

BACKGROUND: This study investigates the clinical use of neuroleptics within a general hospital in acutely ill medical or surgical patients and its relation with dementia three months after admission compared with control subjects. METHODS: Cases were defined as every adult patient to whom a neuroleptic medication was prescribed during their hospitalization in our Hospital from February 1(st), to June 30(th), 1998. A control matched by age and sex was randomly selected among patients who had been admitted in the same period, in the same department, and had not received neuroleptics drugs (205 cases and 200 controls). Demographic, clinical and complementary data were compared between cases and controls. Crude odds ratios estimating the risk of dementia in non previously demented subjects compared with the risk in non-demented control subjects were calculated. RESULTS: 205 of 2665 patients (7.7%) received a neuroleptic drug. The mean age was 80.0 ± 13.6 years and 52% were females. They were older and stayed longer than the rest of the population. Only 11% received a psychological evaluation before the prescription. Fifty two percent were agitated while 40% had no reason justifying the use of neuroleptic drug. Three months after neuroleptic use 27% of the surviving cases and 2.6% of the surviving controls who were judged non-demented at admission were identified as demented. CONCLUSIONS: The most common reason for neuroleptic treatment was to manage agitation symptomatically in hospitalised patients. Organic mental syndromes were rarely investigated, and mental status exams were generally absent. Most of neuroleptic recipients had either recognised or unrecognised dementia