Can Comprehensive Geriatric Assessment be delivered without the need for geriatricians? A formative evaluation in two perioperative surgical settings

Introduction The aim of this study was to design an approach to improving care for frail older patients in hospital services where Comprehensive Geriatric Assessment (CGA) was not part of the clinical tradition. Methods The intervention was based on the principles of CGA, using quality improvement methodology to embed care processes. Qualitative methods and coproduction were used to inform development of the intervention, which was directed towards the health care professionals involved in peri-operative/surgical cancer care pathways in two large UK teaching hospitals. A formative, qualitative evaluation was undertaken; data collection and analysis were guided by Normalisation Process Theory. Results The clinicians involved agreed to use the toolkit, identifying potential benefits including improved surgical decision making and delivery of interventions pre-operatively. However, sites concluded that pre-operative assessment was not the best place for CGA, and at the end of the 12-month trial, implementation was still nascent. Efforts competed against the dominance of national time-limited targets, and concerns relating to patients’ immediate treatment and recovery. Some participants involved in the peri-operative pathway felt that CGA required ongoing specialist input from geriatricians, but it was not clear that this was sustainable. Conclusions Clinical toolkits designed to empower non-geriatric teams to deliver CGA were received with initial enthusiasm, but did not fully achieve their stated aims due to the need for an extended period of service development with geriatrician support, competing priorities, and divergent views about appropriate professional domains.NIH

Understanding variation in unplanned admissions of people aged 85 and over:a systems-based approach

AIM: To examine system characteristics associated with variations in unplanned admission rates in those aged 85+.DESIGN: Mixed methods.SETTING: Primary care trusts in England were ranked according to changes in admission rates for people aged 85+ between 2007 and 2009, and study sites selected from each end of the distribution: three 'improving' sites where rates had declined by more than 4% and three 'deteriorating' sites where rates had increased by more than 20%. Each site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services and adult social care.PARTICIPANTS: A total of 142 representatives from these organisations were interviewed to understand how policies had been developed and implemented. McKinsey's 7S framework was used as a structure for investigation and analysis.RESULTS: In general, improving sites provided more evidence of comprehensive system focused strategies backed by strong leadership, enabling the development and implementation of policies and procedures to avoid unnecessary admissions of older people. In these sites, primary and intermediate care services appeared more comprehensive and better integrated with other parts of the system, and policies in emergency departments were more focused on providing alternatives to admission.CONCLUSIONS: Health and social care communities which have attenuated admissions of people aged 85+ prioritised developing a shared vision and strategy, with sustained implementation of a suite of interventions.</p

Why are we misdiagnosing urinary tract infection in older patients? A qualitative inquiry and roadmap for staff behaviour change in the emergency department

Purpose - The aim of this study was to identify the psychological and behavioural factors influencing clinicians managing older people with possible UTI in urgent care settings, and to develop an improvement roadmap. Methods - Michie’s behaviour change wheel and COM-B (Capability, Opportunity, Motivation, Behaviour Change) models were used as the theoretical basis for this study. Semi-structured interviews were undertaken with 21 purposively selected medical and nursing staff in a large urban emergency department in the East Midlands, United Kingdom. Analysis was informed by the framework approach. A participatory design approach was used to develop an improvement roadmap. Results - Key themes emerging from the semi-structured interviews included lack of knowledge on the role of urine dipstick testing, bias towards older people, automatic testing, time and resource constraints, pressures from peers and patients, and fear of the legal consequences of inaction. A thematic networks map indicated complex interactions between psychological and behavioural factors. Among more than 50 different intervention ideas identified by the workshop participants, two interventions were prioritised for implementation: i) controlling the use of dip stick urine tests; ii) providing individualised feedback to staff regarding the outcomes of patients diagnosed and treated for UTI. Conclusions - Psychological and behavioural factors play a significant role in the misdiagnosis of UTI in older people. Systematic approaches incorporating these factors might improve patient outcomes. Future studies should focus on implementation and evaluating their effectiveness and sustainability

Face processing limitation to own species in primates: a comparative study in brown capuchins, Tonkean macaques and humans

Most primates live in social groups which survival and stability depend on individuals' abilities to create strong social relationships with other group members. The existence of those groups requires to identify individuals and to assign to each of them a social status. Individual recognition can be achieved through vocalizations but also through faces. In humans, an efficient system for the processing of own species faces exists. This specialization is achieved through experience with faces of conspecifics during development and leads to the loss of ability to process faces from other primate species. We hypothesize that a similar mechanism exists in social primates. We investigated face processing in one Old World species (genus Macaca) and in one New World species (genus Cebus). Our results show the same advantage for own species face recognition for all tested subjects. This work suggests in all species tested the existence of a common trait inherited from the primate ancestor: an efficient system to identify individual faces of own species only

Establishing and implementing best practice to reduce unplanned admissions in those aged 85 years and over through system change [Establishing System Change for Admissions of People 85+ (ESCAPE 85+)]: a mixed-methods case study approach

Background: In England, between 2007/8 and 2009/10, the rate of unplanned hospital admissions of people aged 85 years and above rose from 48 to 52 per 100. There was substantial variation, with some areas showing a much faster rate of increase and others showing a decline. Objectives: To identify system characteristics associated with higher and lower increases in unplanned admission rates in those aged 85 years and over; to develop recommendations to inform providers and commissioners; and to investigate the challenges of starting to implement these recommendations. Design: Mixed-methods study using routinely collected data, in-depth interviews and focus groups. Data were analysed using the framework approach, with themes following McKinsey’s 7S model. Recommendations derived from our findings were refined and prioritised through respondent validation and consultation with the project steering group. The process of beginning to implement these recommendations was examined in one ‘implementation site’. Participants: Six study sites were selected based on admission data for patients aged 85 years and above from primary care trusts: three where rates of increase were among the most rapid and three where they had slowed down or declined. Each ‘improving’ or ‘deteriorating’ site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services, and adult social care. At each site, representatives from these organisations at strategic and operational levels, as well as representatives of patient groups, were interviewed to understand how policies had been developed and implemented. A total of 142 respondents were interviewed. Results: Between 2007/8 and 2009/10, average admission rates for people aged 85 years and over rose by 5.5% annually in deteriorating sites and fell by 1% annually in improving sites. During the period under examination, the population aged 85 years and over in deteriorating sites increased by 3.4%, compared with 1.3% in improving sites. In deteriorating sites, there were problems with general practitioner access, pressures on emergency departments and a lack of community-based alternatives to admission. However, the most striking difference between improving and deteriorating sites was not the presence or absence of specific services, but the extent to which integration within and between types of service had been achieved. There were also overwhelming differences in leadership, culture and strategic development at the system level. The final list of recommendations emphasises the importance of issues such as maximising integration of services, strategic leadership and adopting a system-wide approach to reconfiguration. Conclusions: Rising admission rates for older people were seen in places where several parts of the system were under strain. Places which had stemmed the rising tide of admissions had done so through strong, stable leadership, a shared vision and strategy, and common values across the system. Future work: Research on individual components of care for older people needs to take account of their impact on the system as a whole. Areas where more evidence is needed include the impact of improving access and continuity in primary care, the optimal capacity for intermediate care and how the frail elderly can best be managed in emergency departments

Understanding variation in unplanned admissions of people aged 85 and over: a systems-based approach

Aim: To examine system characteristics associated with variations in unplanned admission rates in those aged 85+. Design: Mixed methods. Setting: Primary care trusts in England were ranked according to changes in admission rates for people aged 85+ between 2007 and 2009, and study sites selected from each end of the distribution: three ‘improving’ sites where rates had declined by more than 4% and three ‘deteriorating’ sites where rates had increased by more than 20%. Each site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services and adult social care. Participants: A total of 142 representatives from these organisations were interviewed to understand how policies had been developed and implemented. McKinsey’s 7S framework was used as a structure for investigation and analysis. Results: In general, improving sites provided more evidence of comprehensive system focused strategies backed by strong leadership, enabling the development and implementation of policies and procedures to avoid unnecessary admissions of older people. In these sites, primary and intermediate care services appeared more comprehensive and better integrated with other parts of the system, and policies in emergency departments were more focused on providing alternatives to admission. Conclusions: Health and social care communities which have attenuated admissions of people aged 85+ prioritised developing a shared vision and strategy, with sustained implementation of a suite of interventions

Lactate transporters in the context of prostate cancer metabolism: what do we know?

Lactate Transporters in the Context of Prostate Cancer Metabolism: What Do We Know?Metabolic changes during malignant transformation have been noted for many years in tumours. Otto Warburg first reported that cancer cells preferentially rely on glycolysis for energy production, even in the presence of oxygen, leading to the production of high levels of lactate. The crucial role of lactate efflux and exchange within the tumour microenvironment drew attention to monocarboxylate transporters (MCTs). MCTs have been recognized as promising targets in cancer therapy, and their expression was described in a large variety of tumours; however, studies showing how these isoforms contribute to the acquisition of the malignant phenotype are scarce and still unclear regarding prostate cancer. In this review, we focus on the role for MCTs in cell metabolism, supporting the development and progression of prostate cancer, and discuss the exploitation of the metabolic nature of prostate cancer for therapeutic and diagnostic purposes.Pertega Gomes N. received a fellowship from the Portuguese Foundation for Science and Technology (FCT), reference SFRH/BD/61027/2009. This work was supported by the FCT grant, reference PTDC/SAUMET/113415/2009, under the scope of "Programa Operacional Tematico Factores de Competitividade" (COMPETE) of "Quadro Comunitario de Apoio III" and co-financed by Fundo Comunitario Europeu FEDER