Early detection of delirium in older medical inpatients: prodrome, predictors and motor subtyping

Background Delirium is highly prevalent, especially in older patients. It independently leads to adverse outcomes, but remains under-detected, particularly hypoactive forms. Although early identification and intervention is important, delirium prevention is key to improving outcomes. The delirium prodrome concept has been mooted for decades, but remains poorly characterised. Greater understanding of this prodrome would promote prompt identification of delirium-prone patients, and facilitate improved strategies for delirium prevention and management. Methods Medical inpatients of ≥70 years were screened for prevalent delirium using the Revised Delirium Rating Scale (DRS--‐R98). Those without prevalent delirium were assessed daily for delirium development, prodromal features and motor subtype. Survival analysis models identified which prodromal features predicted the emergence of incident delirium in the cohort in the first week of admission. The Delirium Motor Subtype Scale-4 was used to ascertain motor subtype. Results Of 555 patients approached, 191 patients were included in the prospective study. The median age was 80 (IQR 10) and 101 (52.9%) were male. Sixty-one patients developed incident delirium within a week of admission. Several prodromal features predicted delirium emergence in the cohort. Firstly, using a novel Prodromal Checklist based on the existing literature, and controlling for confounders, seven predictive behavioural features were identified in the prodromal period (for example, increasing confusion; and being easily distractible). Additionally, using serial cognitive tests and the DRS-R98 daily, multiple cognitive and other core delirium features were detected in the prodrome (for example inattention; and sleep-wake cycle disturbance). Examining longitudinal motor subtypes in delirium cases, subtypes were found to be predominantly stable over time, the most prevalent being hypoactive subtype (62.3%). Discussion This thesis explored multiple aspects of delirium in older medical inpatients, with particular focus on the characterisation of the delirium prodrome. These findings should help to inform future delirium educational programmes, and detection and prevention strategies.

Nanofiber control of ultracold quantum gases

While a great amount of attention is being given to the development of nanodevices, both through academic research and private industry, the field is still on the verge. Progress hinges upon the development of tools and components that can precisely control the interaction between light and matter, and that can be efficiently integrated into nano-devices. Nanofibers are one of the most promising candidates for such purposes. However, in order to fully exploit their potential, a more intimate knowledge of how nanofibers interact with single neutral atoms must be gained. As we learn more about the properties of nanofiber modes, and the way they interface with atoms, and as the technology develops that allows them to be prepared with more precisely known properties, they become more and more adaptable and effective. The work presented in this thesis touches on many topics, which is testament to the broad range of applications and high degree of promise that nanofibers hold. For immediate use, we need to fully grasp how they can be best implemented as sensors, filters, detectors, and switches in existing nano-technologies. Areas of interest also include how they might be best exploited for probing atom-surface interactions, single-atom detection and single photon generation. Nanofiber research is also motivated by their potential integration into fundamental cold atom quantum experiments, and the role they can play there. Combining nanofibers with existing optical and quantum technologies is a powerful strategy for advancing areas like quantum computation, quantum information processing, and quantum communication. In this thesis I present a variety of theoretical work, which explores a range of the applications listed above. The first work presented concerns the use of the evanescent fields around a nanofiber to manipulate an existing trapping geometry and therefore influence the centre-of-mass dynamics of the atom. The second work presented explores interesting trapping geometries that can be achieved in the vicinity of a fiber in which just four modes are allowed to propagate. In a third study I explore the use of a nanofiber as a detector of small numbers of photons by calculating the rate of emission into the fiber modes when the fiber is moved along next to a regularly separated array of atoms. Also included are some results from a work in progress, where I consider the scattered field that appears along the nanofiber axis when a small number of atoms trapped along that axis are illuminated orthogonally; some interesting preliminary results are outlined. Finally, in contrast with the rest of the thesis, I consider some interesting physics that can be done in one of the trapping geometries that can be created around the fiber, here I explore the ground states of a phase separated two-component superfluid Bose-Einstein condensate trapped in a toroidal potential.

Nanofabrication towards biophotonics

This thesis explores methods for fabrication of nanohole arrays, and their integration into a benchtop system for use as sensors or anti-counterfeit labels. Chapter 1 gives an introduction to plasmonics and more specifically nanohole arrays and how they have potential as label free sensors compared to the current biosensors on the market. Various fabrication methods are explored, including Focused Ion Beam, Electron Beam Lithography, Nanoimprint lithography, Template stripping and Phase Shift Lithography. Focused Ion Beam was chosen to fabricate the nanohole arrays due to its suitability for rapid prototyping and it’s relatively low cost. In chapter 2 the fabrication of nanohole arrays using FIB is described, and the samples characterised. The fabricated nanohole arrays are tested as bulk refractive index sensors, before a bioassay using whole molecule human IgG antibodies and antigen is developed and performed on the senor. In chapter 3 the fabricated sensors are integrated into a custom built system, capable of real time, multiplexed detection of biomolecules. Here, scFv antibodies of two biomolecules relevant to the detection of pancreatic cancer (C1q and C3) are attached to the nanohole arrays, and detection of their complementary proteins is demonstrated both in buffer (10 nM detection of C1q Ag) and human serum. Chapter 4 explores arrays of anisotropic (elliptical) nanoholes and shows how the shape anisotropy induces polarisation sensitive transmission spectra, in both simulations and fabricated arrays. The potential use of such samples as visible and NIR tag for anti-counterfeiting applications is demonstrated. Finally, chapter 5 gives a summary of the work completed and discusses potential future work in this area.

Use of fluorescence lifetime imaging microscopy (FLIM) as a timer of cell cycle S phase

Incorporation of thymidine analogues in replicating DNA, coupled with antibody and fluorophore staining, allows analysis of cell proliferation, but is currently limited to monolayer cultures, fixed cells and end-point assays. We describe a simple microscopy imaging method for live real-time analysis of cell proliferation, S phase progression over several division cycles, effects of anti-proliferative drugs and other applications. It is based on the prominent (~ 1.7-fold) quenching of fluorescence lifetime of a common cell-permeable nuclear stain, Hoechst 33342 upon the incorporation of 5-bromo-2’-deoxyuridine (BrdU) in genomic DNA and detection by fluorescence lifetime imaging microscopy (FLIM). We show that quantitative and accurate FLIM technique allows high-content, multi-parametric dynamic analyses, far superior to the intensity-based imaging. We demonstrate its uses with monolayer cell cultures, complex 3D tissue models of tumor cell spheroids and intestinal organoids, and in physiological study with metformin treatment.