Study protocol: Investigation of the Delirium Observation Screening Scale (DOSS) for the routine detection of delirium in the care home setting: a prospective cohort study

Introduction: Delirium is a common and distressing condition associated with frailty, dementia and co-morbidity. These are common in long-term care settings. Residents in care homes are therefore at particular risk of delirium. Despite this, methods to detect delirium in care homes are lacking, with existing diagnostic tools taking too long, or requiring specific training to deliver. This limits their feasibility for use for the routine detection of delirium by care home staff. Routine screening for delirium in care homes would allow timely attention to exacerbating factors to attenuate the episode, and facilitate future research into delirium in the care home environment. Methods: Residents from four large care homes will be asked to consent (or their consultees asked to provide a declaration of agreement) to participate in the study. Care home staff will administer the 25-item Delirium Observation Screening Scale (DOSS) – a delirium screening tool based on observed behaviours and this will be tested against the research standard Confusion Assessment Method (CAM) administered by trained research assistants performed twice per week for all participating residents. Analysis: Sensitivity, specificity, positive and negative predictive values, likelihood ratios and a diagnostic odds ratio will be calculated for the detection of delirium with the 25-item DOSS. The feasibility of routine delirium screening and the scaling properties of the 25-item DOSS will also be explored. Ethics and Dissemination: For residents lacking capacity to participate, a consultee will be approached for a declaration of agreement for inclusion in the study. Results will be published in peer-reviewed journals and disseminated in written format to Clinical Commissioning Groups, General Practitioners, and relevant third parties. Registration details: This study is registered on the ISRCTN registry (ISRCTN14608554

Brain size and brain/intracranial volume ratio in major mental illness

<p>Abstract</p> <p>Background</p> <p>This paper summarizes the findings of a long term study addressing the question of how several brain volume measure are related to three major mental illnesses in a Colorado subject group. It reports results obtained from a large N, collected and analyzed by the same laboratory over a multiyear period, with visually guided MRI segmentation being the primary initial analytic tool.</p> <p>Methods</p> <p>Intracerebral volume (ICV), total brain volume (TBV), ventricular volume (VV), ventricular/brain ratio (VBR), and TBV/ICV ratios were calculated from a total of 224 subject MRIs collected over a period of 13 years. Subject groups included controls (C, N = 89), and patients with schizophrenia (SZ, N = 58), bipolar disorder (BD, N = 51), and schizoaffective disorder (SAD, N = 26).</p> <p>Results</p> <p>ICV, TBV, and VV measures compared favorably with values obtained by other research groups, but in this study did not differ significantly between groups. TBV/ICV ratios were significantly decreased, and VBR increased, in the SZ and BD groups compared to the C group. The SAD group did not differ from C on any measure.</p> <p>Conclusions</p> <p>In this study TBV/ICV and VBR ratios separated SZ and BD patients from controls. Of interest however, SAD patients did not differ from controls on these measures. The findings suggest that the gross measure of TBV may not reliably differ in the major mental illnesses to a degree useful in diagnosis, likely due to the intrinsic variability of the measures in question; the differences in VBR appear more robust across studies. Differences in some of these findings compared to earlier reports from several laboratories finding significant differences between groups in VV and TBV may relate to phenomenological drift, differences in analytic techniques, and possibly the "file drawer problem".</p

Validation and Recalibration of Two Multivariable Prognostic Models for Survival and Independence in Acute Stroke

Introduction Various prognostic models have been developed for acute stroke, including one based on age and five binary variables (‘six simple variables’ model; SSVMod) and one based on age plus scores on the National Institutes of Health Stroke Scale (NIHSSMod). The aims of this study were to externally validate and recalibrate these models, and to compare their predictive ability in relation to both survival and independence. Methods Data from a large clinical trial of oxygen therapy (n = 8003) were used to determine the discrimination and calibration of the models, using C-statistics, calibration plots, and Hosmer-Lemeshow statistics. Methods of recalibration in the large and logistic recalibration were used to update the models. Results For discrimination, both models functioned better for survival (C-statistics between .802 and .837) than for independence (C-statistics between .725 and .735). Both models showed slight shortcomings with regard to calibration, over-predicting survival and under-predicting independence; the NIHSSMod performed slightly better than the SSVMod. For the most part, there were only minor differences between ischaemic and haemorrhagic strokes. Logistic recalibration successfully updated the models for a clinical trial population. Conclusions Both prognostic models performed well overall in a clinical trial population. The choice between them is probably better based on clinical and practical considerations than on statistical considerations

Role of the Arabidopsis PIN6 auxin transporter in auxin homeostasis and auxin-mediated development

Plant-specific PIN-formed (PIN) efflux transporters for the plant hormone auxin are required for tissue-specific directional auxin transport and cellular auxin homeostasis. The Arabidopsis PIN protein family has been shown to play important roles in developmental processes such as embryogenesis, organogenesis, vascular tissue differentiation, root meristem patterning and tropic growth. Here we analyzed roles of the less characterised Arabidopsis PIN6 auxin transporter. PIN6 is auxin-inducible and is expressed during multiple auxin–regulated developmental processes. Loss of pin6 function interfered with primary root growth and lateral root development. Misexpression of PIN6 affected auxin transport and interfered with auxin homeostasis in other growth processes such as shoot apical dominance, lateral root primordia development, adventitious root formation, root hair outgrowth and root waving. These changes in auxin-regulated growth correlated with a reduction in total auxin transport as well as with an altered activity of DR5-GUS auxin response reporter. Overall, the data indicate that PIN6 regulates auxin homeostasis during plant development.Christopher I. Cazzonelli, Marleen Vanstraelen, Sibu Simon, Kuide Yin, Ashley Carron-Arthur, Nazia Nisar, Gauri Tarle, Abby J. Cuttriss¤, Iain R. Searle, Eva Benkova, Ulrike Mathesius, Josette Masle, Jiří Friml, Barry J. Pogso

Patient Safety in Internal Medicine

AbstractHospital Internal Medicine (IM) is the branch of medicine that deals with the diagnosis and non-surgical treatment of diseases, providing the comprehensive care in the office and in the hospital, managing both common and complex illnesses of adolescents, adults, and the elderly. IM is a key ward for Health National Services. In Italy, for example, about 17.3% of acute patients are discharged from the IM departments. After the epidemiological transition to chronic/degenerative diseases, patients admitted to hospital are often poly-pathological and so requiring a global approach as in IM. As such transition was not associated—with rare exceptions—to hospital re-organization of beds and workforce, IM wards are often overcrowded, burdened by off-wards patients and subjected to high turnover and discharge pressure. All these factors contribute to amplify some traditional clinical risks for patients and health operators. The aim of our review is to describe several potential errors and their prevention strategies, which should be implemented by physicians, nurses, and other healthcare professionals working in IM wards

Fluorescent amino acids as versatile building blocks for chemical biology

Fluorophores have transformed the way we study biological systems, enabling non-invasive studies in cells and intact organisms, which increase our understanding of complex processes at the molecular level. Fluorescent amino acids have become an essential chemical tool because they can be used to construct fluorescent macromolecules, such as peptides and proteins, without disrupting their native biomolecular properties. Fluorescent and fluorogenic amino acids with unique photophysical properties have been designed for tracking protein–protein interactions in situ or imaging nanoscopic events in real time with high spatial resolution. In this Review, we discuss advances in the design and synthesis of fluorescent amino acids and how they have contributed to the field of chemical biology in the past 10 years. Important areas of research that we review include novel methodologies to synthesize building blocks with tunable spectral properties, their integration into peptide and protein scaffolds using site-specific genetic encoding and bioorthogonal approaches, and their application to design novel artificial proteins, as well as to investigate biological processes in cells by means of optical imaging. [Figure not available: see fulltext.]

A prospective observational study to investigate utility of the Delirium Observational Screening Scale (DOSS) to detect delirium in care home residents

Background: Care home residents are particularly at risk of delirium due to high prevalence of dementia. The Delirium Observation Screening Scale (DOSS) identifies behavioural changes associated delirium onset that nursing staff are uniquely placed to recognise. We tested the psychometric properties of the DOSS in UK care homes compared with the Confusion Assessment Method (CAM). Design: Prospective observational cohort study performed between 01/03/2015 and 30/06/2016. Setting: 9 UK residential and nursing care homes. Subjects: Residents over 65 years except those approaching end of life or unable to complete delirium assessments. Methods: The 25-item DOSS was completed daily by care home staff and compared with the temporally closest CAM performed twice per week by trained researchers. Sensitivity, specificity, positive and negative predictive values, diagnostic odds and likelihood ratios were calculated. Results: 216 residents participated; mean age 84.9 (SD 7.9); 50% had cognitive impairment (median AMTS 7 (IQR 3 to 9)). Half of all expected DOSS assessments occurred (30,201); of these, 11,659 (39%) were complete. 78 positive CAM measurements were made during 71 delirium episodes in 45 residents over 70 weeks. Sensitivity and specificity for delirium detection were optimised at a DOSS cut-point of >=5 (sensitivity 0.61 (95% CI: 0.39-0.80) and specificity (0.71 95% CI: 0.70-0.73)). Positive and negative predictive values were 1.6% and 99.5% respectively. Conclusions: The low sensitivity of the DOSS limits clinical utility for detection of delirium as part of routine care for care home residents, although a negative DOSS affords confidence that delirium is not present

In-hospital stress and patient outcomes: A systematic review and meta-analysis

Background Hospital inpatients are exposed to high levels of stress during hospitalisation that may increase susceptibility to major adverse health events post-hospitalisation (known as post-hospital syndrome). However, the existing evidence base has not been reviewed and the magnitude of this relationship remains unknown. Therefore, the aim of the current systematic review and meta-analysis was to: 1) synthesise existing evidence and to determine the strength of the relationship between in-hospital stress and patient outcomes, and 2) determine if this relationship differs between (i) in-hospital vs post-hospital outcomes, and (ii) subjective vs objective outcome measures. Methods A systematic search of MEDLINE, EMBASE, PsychINFO, CINAHL, and Web of Science from inception to February 2023 was conducted. Included studies reported a measure of perceived and appraised stress while in hospital, and at least one patient outcome. A random-effects model was generated to pool correlations (Pearson’s r), followed by sub-group and sensitivity analyses. The study protocol was preregistered on PROSPERO (CRD42021237017). Results A total of 10 studies, comprising 16 effects and 1,832 patients, satisfied the eligibility criteria and were included. A small-to-medium association was found: as in-hospital stress increased, patient outcomes deteriorated (r = 0.19; 95% CI: 0.12–0.26; I2 = 63.6; p < 0.001). This association was significantly stronger for (i) in-hospital versus post-hospital outcomes, and (ii) subjective versus objective outcome measures. Sensitivity analyses indicated that our findings were robust. Conclusions Higher levels of psychological stress experienced by hospital inpatients are associated with poorer patient outcomes. However, more high-quality, larger scale studies are required to better understand the association between in-hospital stressors and adverse outcomes