A sinking heart: Whose problem is it? Under fives work in the surgery of a general practitioner.

Book Synopsis. This volume is the result of over twenty years of therapeutic interventions with families within the Tavistock Clinic's Under Fives Service. It describes in detail the process of understanding young children's communications and behaviour and the dynamics of family relationships within the consulting room in a lively, accessible style. It covers common themes in work with young children such as disruptive, angry behaviour, separation and sleep difficulties, and problems in the parent/couple relationship. This book is essential reading for all early years professionals hoping to gain a greater understanding of the technique, observational skills and theory which underlie a psychodynamic approach to work with the under fives

Ecological studies of Clostridioides difficile and COVID-19 infection with the application of space-time risk models

Date on title page is 2021. Degree awarded in 2022.Infectious diseases continue to pose major global health threats. With the recent devastation from the COVID-19 pandemic and growing concerns of healthcare-associated infections (HAIs), there is a worldwide requirement for stringent techniques to monitor and understand the key drivers for infections. Infectious diseases have an inherent spatial dimension due to the contagious nature of viruses and bacteria. This thesis aims to explore the use of spatial and spatio-temporal techniques applied to infections, specifically Clostridiodies difficile infection (CDI) and COVID-19, to identify risk factors at an ecological population-based level. A mixture of open-sourced and routinely collected data, at different spatial scales, were used to understand the surveillance capacities of observational public health data. Antimicrobial prescribing and stewardship have been a global focus in the last decade as concerns have grown with emergent novel antibiotic-resistant infections. CDI has been shown to have a well-defined association with certain broad-spectrum antibiotic classes and other environmental factors, however, there is a gap in the literature aiming to understand these relationships ecologically and spatially. The main focus of this thesis was to use spatio-temporal models to investigate spatial risk factors of CDI incidence, such as GP antimicrobial prescribing, in Scotland and Wales. Similar spatial techniques were then applied to investigate the spatial distribution of COVID-19 testing during the first wave of the 2020 epidemic in Scotland. The relevant spatial and spatio-temporal models applied throughout this thesis were initially discussed in Chapter 2. The spatial distribution of Scottish GP antibiotic prescribing rates, from 2016 to 2018, was investigated in Chapter 3 using spatial point-location correlation methods. Risk factors of increased GP antibiotic prescribing were explored, showing GP practice demographic information as key drivers of increased antibiotic prescribing. These analyses were followed by an exploration of Scottish CDI incidence data, from 2014 to 2018, at a small areal level (intermediate zones (IZ)), to understand spatial auto-correlation and temporal trends of CDI incidence in Chapter 4. Population demographic risk factors, as highlighted in the literature, were obtained at the same spatial scale and assessed as ecological risk factors of CDI incidence using conditional autoregressive (CAR) models. The next phase of this thesis then combined the previous two analyses, introducing a multi-level spatial problem, which aimed to explore central risk factors of CDI that were not available at the same spatial scale in Chapter 5. Spatial interpolation methods were applied to manipulate GP antibiotic prescribing point-location data and areal-unit cattle density data to match the CDI incidence at an IZ spatial scale. These data could then be explored as ecological risk factors of CDI incidence, carrying forward the previously defined CAR model from Chapter 4 and adjusting for demographic confounders. Welsh CDI incidence and primary care antibiotic prescribing data offered the opportunity to compare between two countries in the UK. The retrospective ecological study in Chapter 6 used aggregated disease surveillance data to understand the impact of total and high-risk Welsh GP antibiotic prescribing on total and stratified inpatient/noninpatient CDI incidence. Location and health board information were anonymised preventing a formal spatial analysis, however, the results were comparable to previous chapter findings and supported the hypothesis of an increased risk of CDI incidence reflected in GP antibiotic prescribing rates, particularly high-risk antibiotics, and population demographics. Finally, at the beginning of the COVID-19 pandemic, it became evident that the methodologies applied in this thesis could support the investigation of the spread of COVID-19 infections. The work presented in Chapter 7 aimed to explore how best to capture spatial patterns of community COVID-19 infection by conducting a spatiotemporal analysis on three data streams { positive test rates, relevant NHS24 calls and COVID Symptom Study (CSS) predicted cases, to assess which was best for early disease surveillance. Results showed both sources to identify similar trends of COVID-19 and gold-standard testing data, particularly when used in parallel. This thesis has provided new insights into the associated risks between CDI incidence and GP antibiotic prescribing in Scotland and Wales, demonstrating the capabilities of open-source and routinely collected public health data when applied in a spatial framework. These results support the requirement of stringent measures to reduce antibiotic prescribing in the community. It also highlights the beneficial use and suitability of analysing infectious disease data with spatial techniques to address gaps in the literature to understand population-based risk factors of disease. There is a strong argument for future research into methods of analysing multi-level spatial data, particularly in the application of observational public health data.Infectious diseases continue to pose major global health threats. With the recent devastation from the COVID-19 pandemic and growing concerns of healthcare-associated infections (HAIs), there is a worldwide requirement for stringent techniques to monitor and understand the key drivers for infections. Infectious diseases have an inherent spatial dimension due to the contagious nature of viruses and bacteria. This thesis aims to explore the use of spatial and spatio-temporal techniques applied to infections, specifically Clostridiodies difficile infection (CDI) and COVID-19, to identify risk factors at an ecological population-based level. A mixture of open-sourced and routinely collected data, at different spatial scales, were used to understand the surveillance capacities of observational public health data. Antimicrobial prescribing and stewardship have been a global focus in the last decade as concerns have grown with emergent novel antibiotic-resistant infections. CDI has been shown to have a well-defined association with certain broad-spectrum antibiotic classes and other environmental factors, however, there is a gap in the literature aiming to understand these relationships ecologically and spatially. The main focus of this thesis was to use spatio-temporal models to investigate spatial risk factors of CDI incidence, such as GP antimicrobial prescribing, in Scotland and Wales. Similar spatial techniques were then applied to investigate the spatial distribution of COVID-19 testing during the first wave of the 2020 epidemic in Scotland. The relevant spatial and spatio-temporal models applied throughout this thesis were initially discussed in Chapter 2. The spatial distribution of Scottish GP antibiotic prescribing rates, from 2016 to 2018, was investigated in Chapter 3 using spatial point-location correlation methods. Risk factors of increased GP antibiotic prescribing were explored, showing GP practice demographic information as key drivers of increased antibiotic prescribing. These analyses were followed by an exploration of Scottish CDI incidence data, from 2014 to 2018, at a small areal level (intermediate zones (IZ)), to understand spatial auto-correlation and temporal trends of CDI incidence in Chapter 4. Population demographic risk factors, as highlighted in the literature, were obtained at the same spatial scale and assessed as ecological risk factors of CDI incidence using conditional autoregressive (CAR) models. The next phase of this thesis then combined the previous two analyses, introducing a multi-level spatial problem, which aimed to explore central risk factors of CDI that were not available at the same spatial scale in Chapter 5. Spatial interpolation methods were applied to manipulate GP antibiotic prescribing point-location data and areal-unit cattle density data to match the CDI incidence at an IZ spatial scale. These data could then be explored as ecological risk factors of CDI incidence, carrying forward the previously defined CAR model from Chapter 4 and adjusting for demographic confounders. Welsh CDI incidence and primary care antibiotic prescribing data offered the opportunity to compare between two countries in the UK. The retrospective ecological study in Chapter 6 used aggregated disease surveillance data to understand the impact of total and high-risk Welsh GP antibiotic prescribing on total and stratified inpatient/noninpatient CDI incidence. Location and health board information were anonymised preventing a formal spatial analysis, however, the results were comparable to previous chapter findings and supported the hypothesis of an increased risk of CDI incidence reflected in GP antibiotic prescribing rates, particularly high-risk antibiotics, and population demographics. Finally, at the beginning of the COVID-19 pandemic, it became evident that the methodologies applied in this thesis could support the investigation of the spread of COVID-19 infections. The work presented in Chapter 7 aimed to explore how best to capture spatial patterns of community COVID-19 infection by conducting a spatiotemporal analysis on three data streams { positive test rates, relevant NHS24 calls and COVID Symptom Study (CSS) predicted cases, to assess which was best for early disease surveillance. Results showed both sources to identify similar trends of COVID-19 and gold-standard testing data, particularly when used in parallel. This thesis has provided new insights into the associated risks between CDI incidence and GP antibiotic prescribing in Scotland and Wales, demonstrating the capabilities of open-source and routinely collected public health data when applied in a spatial framework. These results support the requirement of stringent measures to reduce antibiotic prescribing in the community. It also highlights the beneficial use and suitability of analysing infectious disease data with spatial techniques to address gaps in the literature to understand population-based risk factors of disease. There is a strong argument for future research into methods of analysing multi-level spatial data, particularly in the application of observational public health data

Case Study: The nutritional management of a patient with acute myeloid leukaemia

No Abstract

A repertory grid study of anorexia nervosa in females

As an exploratory study, a sample of five anorexia nervosa subjects, diagnosed on standardized criteria, were tested while hospitalized for treatment, on elicited and assigned construct repertory grids, where the latter grid's construction reflected aspects of central interest to the syndrome. The two repertory grids for each subject were processed using Slater's (1972) "INGRID 72 PROGRAM : the principal components analysis for the repertory grid", and comprehensive data is tabulated and discussed with reference to each subject's psychological grid space. A comparison of the efficacy of the two repertory grid measures is discussed and nomothetic data is descriptively presented and viewed in terms of the literature. Suggestions for more refined repertory grid investigation in this area are forwarded

Glutamine and its use in selected oncology settings

This review summarises the latest evidence for the use of glutamine (GLN) in  oncology taking cognisance of current systematic reviews and available guidelines. Various studies in adults suggest that GLN supplementation suppresses tumour  growth, by restoring the function of natural killer cells; improves protein metabolism; and, possibly enhances the effect of cancer therapy. There is insufficient data on whether GLN supplementation reduces the incidence of infection, although a trend exists towards such a reduction. GLN-supplemented enteral nutrition was superior in improving immune function, whilst oral GLN alone appeared to have no effect on: mortality; infections; time to neutrophil recovery; or, relapse. GLN significantly reduces the duration of diarrhoea, but had no effect on its prevention. Oral GLN may reduce the duration and severity of mucositis, with fewer days on opioid therapy. Oral GLN, but not intravenous GLN (IV-GLN), may decrease mucositis and graft-versus-host disease in adult bone marrow transplant patients. Currently, the  evidence for reduction of severe mucositis or infection rate in children is not statistically significant, but GLN does significantly reduce parenteral nutrition use, reflecting a possible improvement in lower gut mucositis. Nevertheless, too few studies exist to either support or refute that GLN supplementation either reduces the duration of, or prevents the progression to, severe mucositis. In children, there is no significant evidence that IV-GLN supplementation reduces infection rates, hospital length of stay (LOS), graft-versus-host disease, or mortality. Children with solid tumours on chemotherapy receiving oral GLN supplementation showed  significant improvements in some nutritional and immunological parameters, as well as the severity of stomatitis and need for antibiotic therapy. Caution is  recommended when considering provision of IV-GLN to oncology patients who have hepatic or renal insufficiency or failure. Monitoring of hepatic and renal function is recommended. Further studies are needed specifically on the use of glutamine in an oncology setting. Larger, multicentre, randomised placebo-controlled studies are needed in both adult and paediatric oncology populations.Keywords: cancer, glutamine, mucositis, oncolog

Adult malnutrition: prevalence and use of nutrition-related quality indicators in South African public-sector hospitals

Objectives: The aim of this study was to describe the prevalence of malnutrition among adult hospitalised patients in three South African public hospitals and to determine the availability of nutrition-related quality indicators at ward and institutional level. Method: A descriptive, cross-sectional, multi-centre study was used to determine the prevalence of malnutrition, whilst a descriptive exploratory design was used to determine the use of nutrition-related quality indicators for the identification and treatment of malnutrition. A total of 141 adult hospitalised patients in three public hospitals in an urban setting participated. Mid-upper arm circumference (MUAC), body mass index (BMI), and malnutrition universal screening tool (MUST) were used to determine the prevalence of malnutrition or malnutrition risk. A Hospital Nutrition Review Tool (HNRT) determined the use of nutrition-related quality indicators. Results: The overall malnutrition risk according to MUST was 72.3% (48.2% high risk and 24.1% medium risk), whilst 45.4% were malnourished based on MUAC. No routine nutritional screening was conducted in any of the wards to identify patients at nutritional risk. The majority of nurses reported inadequate training or knowledge to calculate patients’ BMI or percentage weight loss, or to perform nutritional screening. Conclusion: Both malnutrition prevalence and malnutrition risk among adult hospitalised patients are high in the public sector. Inadequate resources may lead to delays in malnutrition identification and appropriate nutritional intervention, which may adversely affect both the patient and the institution. This study contributes to baseline data on adult malnutrition in the South African public hospital setting

Mid-upper arm circumference (MUAC) as a feasible tool in detecting adult malnutrition

Objectives: This study aimed to expand on the limited South African malnutrition prevalence data and investigate the feasibility of mid-upper-arm circumference (MUAC) as a malnutrition screening tool. Design: A cross-sectional, multi-centre, descriptive design was adopted. Setting: The study was undertaken in three tertiary public hospitals in the same urban area within the Eastern Cape of South Africa. Subjects: Adult hospitalised patients volunteered to participate (n = 266). Methods: Data were collected using interviewer-administered questionnaires; obtaining anthropometric measurements; and consulting medical files. For maximum accuracy of various MUAC cut-off points, receiver operating characteristic curves were generated and area under the curve determined. Results: Both body mass index (BMI) and MUAC identified 21% of participants as underweight or malnourished, and 39% as overweight or obese. The Malnutrition Universal Screening Tool (MUST) found 23% at increased malnutrition risk. Nurses or doctors detected and referred only 19% of underweight patients (BMI < 18.5 kg/m2), to dietetics services. Direct measurements of BMI and MUST were unobtainable in 38% and 43% of patients respectively, whilst MUAC was obtainable in 100%. A statistically significant relationship (p < 0.001) exists between MUAC, BMI and MUST to detect malnutrition or malnutrition risk. MUAC cut-offs for undernutrition were determined at < 23 cm (BMI < 16 kg/m2) and < 24 cm (BMI < 18.5 kg/m2), respectively, for the study’s population groups. Conclusion: Malnutrition prevalence was high in this study, but often unidentified, with only a fifth referred to dietetic services. MUAC is a feasible method to identify adult malnutrition and should be considered as a malnutrition screening tool and key nutritional status indicator in South African public hospitals