What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review

Abstract Background Emergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address. Objectives To systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes. Design A systematic mapping review. Setting Evidence from developed countries on interventions delivered in the ED. Participants Frail and high-risk older people and general populations of older people (aged > 65 years). Interventions Interventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED. Main outcome measures Patient outcomes (direct and indirect) and health service outcomes. Data sources Evidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016. Review methods A review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made. Results Of the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes. Limitations This review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review. Conclusions A substantial body of evidence on interventions for frail and high-risk older people was identified and mapped. Future work Future work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients. Study registration This study is registered as PROSPERO CRD42016043260. Funding The National Institute for Health Research Health Services and Delivery Research programme

Ancient diversification in extreme environments: Exploring the historical biogeography of the Antarctic winged midge Parochlus steinenii (Diptera: Chironomidae)

The terrestrial fauna of Antarctica consists of a limited number of species, notably insects, small crustaceans and other micro-invertebrates. Over long periods of evolutionary isolation, these organisms have developed varying degrees of tolerance to multifaceted environmental stresses. Recent molecular biogeographical research highlights the enduring persistence of much of Antarctica's current terrestrial fauna, with estimates spanning from hundreds of thousands to millions of years. Parochlus steinenii, commonly known as the Antarctic winged midge, stands out as one of the only two insect species native to Antarctica. Distributed across three biogeographic regions, southern South America and the Falkland/Malvinas Islands, sub-Antarctic South Georgia and the Maritime Antarctic South Shetland Islands, this midge raises questions about the temporal isolation of its populations and their divergence. Employing mitochondrial and nuclear genetic markers, we conducted phylogeographic and demographic analyses on 151 individuals of P. steinenii obtained across the three main biogeographic regions including the Magellanic sub-Antarctic Ecoregion (MSE) of southern South America, the sub-Antarctic Island of South Georgia (SG) and the South Shetland Islands (SSI) within the Maritime Antarctic (MA). Our data support the diversification of P. steinenii during the mid-Pleistocene around 1.46 Mya. This period included a branching event between a clade containing only specimens from the MSE and a clade containing individuals from a broader range of locations including the SSI and SG. Based on intraspecific phylogeographic and demographic inferences, we detected strong evolutionary divergence between the three main biogeographic regions. We also detected a signal of population growth during the deglaciation process in SSI and SG, contrary to the pattern seen in the MSE. The different demographic and phylogeographic histories between the sampled biogeographic regions could result from the MA and SG experiencing a strong genetic bottleneck due to a reduction in population size during the Last Glacial Maximum, while the MSE maintained a significant effective population size. The high level of divergence detected between individuals from the MSE and the remaining biogeographic regions supports the hypothesis of a speciation process taking place in P. steinenii

Atomic X-ray Spectroscopy of Accreting Black Holes

Current astrophysical research suggests that the most persistently luminous objects in the Universe are powered by the flow of matter through accretion disks onto black holes. Accretion disk systems are observed to emit copious radiation across the electromagnetic spectrum, each energy band providing access to rather distinct regimes of physical conditions and geometric scale. X-ray emission probes the innermost regions of the accretion disk, where relativistic effects prevail. While this has been known for decades, it also has been acknowledged that inferring physical conditions in the relativistic regime from the behavior of the X-ray continuum is problematic and not satisfactorily constraining. With the discovery in the 1990s of iron X-ray lines bearing signatures of relativistic distortion came the hope that such emission would more firmly constrain models of disk accretion near black holes, as well as provide observational criteria by which to test general relativity in the strong field limit. Here we provide an introduction to this phenomenon. While the presentation is intended to be primarily tutorial in nature, we aim also to acquaint the reader with trends in current research. To achieve these ends, we present the basic applications of general relativity that pertain to X-ray spectroscopic observations of black hole accretion disk systems, focusing on the Schwarzschild and Kerr solutions to the Einstein field equations. To this we add treatments of the fundamental concepts associated with the theoretical and modeling aspects of accretion disks, as well as relevant topics from observational and theoretical X-ray spectroscopy.Comment: 63 pages, 21 figures, Einstein Centennial Review Article, Canadian Journal of Physics, in pres

For science, love and money: the social worlds of poultry and rabbit breeding in Britain, 1900-1940

This paper traces the joint histories of poultry and rabbit breeding by fanciers, and for commercial and scientific purposes, in early 20th-century Britain. I show that the histories of the social worlds that bred for these different purposes are intertwined, as are the histories of poultry and rabbit breeding in general. To properly understand the history of scientific breeding we must therefore understand the general context of breeding in which this occurred. In the paper I show that as fancy poultry and rabbits were taken up for scientific research at the start of the 20th century they became scientific specimens and boundary objects between the social worlds. Their existence as boundary objects motivated the social worlds to coordinate their work through translators and trading zones. By the 1930s all three coordination methods were being used simultaneously

Qualitative theory testing as mixed-method research

While the concept of mixed-methods research is more usually associated with combining quantitative and qualitative approaches, this paper outlines a study that mixed methods by undertaking qualitative theory testing and derivation when examining the relationship between health promotion theory and hospital nursing practice. Thus, it is concerned with relating the metatheoretical aspects of the debate and not with the pragmatic aspects of the research and concomitant methods. A deductive–inductive–deductive design, based on the theory–research–theory strategy of Meleis (1985), tested, revised and developed for nursing established health promotion theory using theory-testing criteria. To complement the methodological mix, the study also used the theory (i.e. a health-promotion taxonomy) as a framework to contextualise the findings rather than generate theory in the way associated with interpretative inquiry. While inconsistent with the traditional view linking theory testing with quantitative, objective epistemology, the process enabled a theoretically robust health-promotion taxonomy to be synthesised and advanced for use in nursing in relation to a paradigm of social thought

What's new pussycat? A genealogy of animal celebrity

Animal celebrity is a human creation informing us about our socially constructed natural world. It is relational, expressive of cultural proclivities, political power plays and the quotidian everyday, as well as serious philosophical reflections on the meaning of being human. This article attempts to outline some key contours in the genealogy of animal celebrity, showing how popular culture, including fairground attractions, public relations, Hollywood movies, documentary films, zoo attractions, commercial sport and mediatised moral panics - particularly those accompanying scientific developments such as cloning - help to order, categorise and license aspects of human understanding and feelings. The nature of [animal] charisma and celebrity are explored with assistance from Jumbo the Elephant, Guy the Gorilla, Paul the clairvoyant octopus, Uggie the film star, Nénette the orang-utan and Dolly the sheep. It argues that the issue of what it is to be human lies beneath the celebritised surface or, as Donna Haraway noted, the issue 'of having to face oneself'