The impact of frailty and polypharmacy on adverse outcomes in older inpatients

Background Older people are at significant risk of adverse outcomes as a result of changes in physiology, frailty, co-morbidity and polypharmacy.1 Timely identification of high-risk patients may facilitate the optimization of medication and reduce the incidence of adverse outcomes. The aims of this study were to evaluate in older inpatients the relationships between risk factors, including frailty and polypharmacy, and adverse health outcomes. Methods This is a prospective study of 1418 patients, aged 70 and older, admitted to general medical units in 11 acute care hospitals across Australia. The interRAI Acute Care (interRAI AC) assessment tool was used for data collection. Frailty status was measured using a Frailty Index (FI), adding each individual’s deficits and dividing by the total number of deficits considered. Adverse health outcomes included falls in hospital, delirium, in-hospital functional and cognitive decline, discharge to a higher level of care and inpatient mortality. Results Patients had a mean age 81 ± 6.8 years with a median length of hospital stay of 6 days (interquartile range 4 to 11 days); 701 (50%) experienced at least one adverse outcome. Polypharmacy (5-9 drugs per day) was observed in almost half of the study population (n=695, 49%) and hyper-polypharmacy (≥10 drugs) observed in about one-third of patients (n=490, 34.6%). Cognitive impairment was shown to be associated with the lower rate of prescribing. FI had a significant association with all adverse outcomes studied (p = <0.05). In contrast, no association was observed between polypharmacy categories and adverse outcomes except for those on 10 or more drugs where they were more likely to be discharged to a higher level of care (p= 0.014). Conclusions Among older inpatients, frailty status was a significant predictor of adverse outcomes. Lower rates of prescribing to patients with cognitive impairment may underpin the lack of an association between polypharmacy and adverse outcomes in this cohort. References: 1. Olsson IN, Runnamo R, Engfeldt P. Medication quality and quality of life in the elderly, a cohort study.Health Qual Life Outcomes.2011;9:95

Depressive symptoms and adverse outcomes from hospitalization in older adults : secondary outcomes of a trial of falls prevention education

Depression is common in older people and symptoms of depression are known to substantially increase during hospitalization. There is little known about predictors of depressive symptoms in older adults or impact of common interventions during hospitalization. This study aimed to describe the magnitude of depressive symptoms, shift of depressive symptoms and the impact of the symptoms of depression among older hospital patients during hospital admission and identify whether exposure to falls prevention education affected symptoms of depression. Participants (n = 1206) were older adults admitted within two Australian hospitals, the majority of participants completed the Geriatric Depression Scale – Short Form (GDS) at admission (n = 1168). Participants’ mean age was 74.7 (±SD 11) years and 47% (n = 551) were male. At admission 53% (619 out of 1168) of participants had symptoms of clinical depression and symptoms remained at the same level at discharge for 55% (543 out of 987). Those exposed to the low intensity education program had higher GDS scores at discharge than those in the control group (low intensity vs control n = 652, adjusted regression coefficient (95% CI) = 0.24 (0.02, 0.45), p = 0.03). The only factor other than admission level of depression that affected depressive symptoms change was if the participant was worried about falling. Older patients frequently present with symptoms of clinical depression on admission to hospital. Future research should consider these factors, whether these are modifiable and whether treatment may influence outcomes.

Functional neuroanatomy of auditory mismatch processing : an event-related fMRI study of duration-deviant oddballs

This study was designed to identify the neural networks underlying automatic auditory deviance detection in 10 healthy subjects using functional magnetic resonance imaging. We measured blood oxygenation level-dependent contrasts derived from the comparison of blocks of stimuli presented as a series of standard tones (50 ms duration) alone versus blocks that contained rare duration-deviant tones (100 ms) that were interspersed among a series of frequent standard tones while subjects were watching a silent movie. Possible effects of scanner noise were assessed by a “no tone” condition. In line with previous positron emission tomography and EEG source modeling studies, we found temporal lobe and prefrontal cortical activation that was associated with auditory duration mismatch processing. Data were also analyzed employing an event-related hemodynamic response model, which confirmed activation in response to duration-deviant tones bilaterally in the superior temporal gyrus and prefrontally in the right inferior and middle frontal gyri. In line with previous electrophysiological reports, mismatch activation of these brain regions was significantly correlated with age. These findings suggest a close relationship of the event-related hemodynamic response pattern with the corresponding electrophysiological activity underlying the event-related “mismatch negativity” potential, a putative measure of auditory sensory memory.

Protecting World Heritage sites from the adverse impacts of climate change : obligations for States Parties to the World Heritage Convention

Through its mandate to protect and preserve places of ‘outstanding universal value’, the World Heritage Convention provides an unlikely yet effective tool in global efforts to mitigate climate change. The practical efficacy of the Strategy to Assist States Parties to Implement Appropriate Management Responses (‘the Strategy’), which represents the World Heritage Committee’s primary response to the threats posed by climate change to World Heritage sites, is undermined by its weak stance on mitigation. This paper argues that the World Heritage Convention imposes stronger obligations on States Parties than those contained in the Strategy, including a duty on States Parties to commit to ‘deep cuts’ in greenhouse gas emissions. In order to ensure the continuing success of the World Heritage Convention States Parties must engage in extensive mitigation strategies without delay.

The second chance project: A multi-level examination of secondary prevention practices for Saudi people following a recent cardiac event

The study examined the health-related behaviours of Saudi people following a recent cardiac event and identified the factors that influence these behaviours using McLeroy et al.'s (1988) Ecological Model of Health Behaviours as a guiding framework. The study was one of the first in Saudi Arabia to examine the health-related behaviours of Saudi people following a recent cardiac event. The study findings emphasise the importance of a program that integrates secondary prevention practices, educational approaches and targeted supportive services in cardiac care in Saudi Arabia.

Log delta analysis: Interpretable differencing of Business process event logs

This paper addresses the problem of identifying and explaining behavioral differences between two business process event logs. The paper presents a method that, given two event logs, returns a set of statements in natural language capturing behavior that is present or frequent in one log, while absent or infrequent in the other. This log delta analysis method allows users to diagnose differences between normal and deviant executions of a process or between two versions or variants of a process. The method relies on a novel approach to losslessly encode an event log as an event structure, combined with a frequency-enhanced technique for differencing pairs of event structures. A validation of the proposed method shows that it accurately diagnoses typical change patterns and can explain differences between normal and deviant cases in a real-life log, more compactly and precisely than previously proposed methods.

Ambient temperature and the rates of adverse reactions of pertussis vaccines

To the Editor—Diphtheria-tetanus-pertussis whole-cell (DTwP) and acellular (DTaP) vaccines are the 2 main pertussis-contained vaccines. DTwP, developed in the 1930s, has contributed to the reduction of pertussis, but has often been associated with vaccine-related adverse reactions (ARs) [1]. This had severely affected the public confidence in immunization programs, followed by decreased vaccine coverage and pertussis outbreaks in many industrialized countries in the 1970s [2]. DTaP, which was developed in the 1980s and replaced DTwP in developed countries in the 1990s, has been associated with fewer ARs due to removal/reduction of endotoxin [1]. China began replacing DTwP with DTaP in its national immunization programs in December 2007, and its passive Adverse Events Following Immunization (AEFI) surveillance system was established in 2005 [3]. The Intergovernmental Panel on Climate Change Fifth Assessment Report indicates that the planet is warming at...

Stress during the rebuilding phase influenced mental health following two Queensland flood disasters more than the event itself

It has long been known that disasters can have mental health consequences such as increased rates of PTSD, depression and anxiety. While some research has shown that secondary stressors during the aftermath of a disaster can influence psychological outcomes, this aspect of the disaster experience has not been widely studied. This paper reports on two studies that investigated which aspects of the experience of being flooded were most predictive of mental health outcomes. The first study was a qualitative study of adults whose homes had been inundated in the Mackay flood of 2008 (n=16). Thematic analysis of interviews conducted 18-20 months post-flood found that stressors during the flood aftermath such as difficulties and delays during the rebuilding process and a difficult experience with an insurance company were nominated as the most stressful aspect of the flood by the majority of participants. The second study surveyed Mackay flood survivors three and a half years post-flood, and Brisbane 2011 flood survivors 7-9 months post-flood (n=158). Findings indicated aftermath stress contributed to mental health outcomes over and above the contribution of perceived trauma, objective flood severity, prior mental health, self-efficacy and demographic factors. The implications of these results for the provision of community recovery services following natural disasters are discussed, including the need to provide effective targeting of support services throughout the lengthy rebuilding phase; a possible role for co-ordinating tradespeople; and training for insurance company staff aimed at minimising the incidence of insurance company staff inadvertently adding to disaster victims’ stress.

Community engagement or community conversation?: Boomtown, a large-scale regional, outdoor community theatrical event

On the 18th of July 2013, three hundred local members of Gladstone, Queensland erupted into song and dance performing the fraught history of their community harbourside through tug boat ballets, taiko drumming, German bell ringing and BMX bike riding. Over 17,500 people attended the four performances of Boomtown, a Queensland Music Festival event. This was the largest regional, outdoor community-engaged musical performance staged in Australia. The narrative moved beyond the dominant, pejorative view of Gladstone as an industrial town to include the community members’ sense of purpose and aspirations. It was a celebratory, contentious and ambitious project that sought to disrupt the traditional conventions of performance-making through working in artistically democratic ways. This article explores the potential for Australian Community Engaged Arts (CEA) projects such as Boomtown to democratically engage community members and co-create culturally meaningful work within a community. Research into CEA projects rarely consider how the often delicate conversations between practitioners and the community work. The complex processes of finding and co-writing the narrative, casting, and rehearsing Boomtown are discussed with reference to artistic director/dramaturge Sean Mee’s innovative approaches. Boomtown began with and concluded with community conversations. Skilful negotiation ensured congruence between the townspeople’s stories and the “community story” presented on stage, abrogating potential problems of narrative ownership. To supplement the research, twenty-one personal interviews were undertaken with Gladstone community members invested in the production before, during and after the project: performers, audience members and local professionals. The stories shared and emphasised in the theatricalised story were based on propitious, meaningful, local stories from lived experiences rather than preconceived, trivial or tokenistic matters, and were underpinned by a consensus formed on what was in the best interests of the majority of community members. Boomtown exposed hidden issues in the community and gave voice to thoughts, feelings and concerns which triggered not just engagement, but honest conversation within the community.

A Deweyan experience economy for higher education : The case of the Australian Indie 100 Music Event

In this essay we argue that a Deweyan experience economy will best support the higher education (HE) sector in the future, and we draw a contrast between that economy and the sector’s current focus on informational concerns, as expressed by the recent rush to Massive Open Online Courses (MOOCs) and other mass online informational offerings. We base our argument on current developments in music education and music technology that we see as being preemptive of wider trends. We use examples from a three-year study of online and offline music pedagogies and outline a four-year experiment in developing a pedagogical experience economy to illustrate a theoretical position informed by John Dewey’s theory of experience,Pierre Bourdieu’s theory of habitus and capital, and recent work in economic geography on epistemic communities. We argue further that the future of the HE sector is local rather than global, experiential rather than informational, and that therefore a continued informational approach to the future of HE risks undermining the sector.

Change visualisation: Analysing the resource and timing differences between two event logs

With organisations facing significant challenges to remain competitive, Business Process Improvement (BPI) initiatives are often conducted to improve the efficiency and effectiveness of their business processes, focussing on time, cost, and quality improvements. Event logs which contain a detailed record of business operations over a certain time period, recorded by an organisation's information systems, are the first step towards initiating evidence-based BPI activities. Given an (original) event log as a starting point, an approach to explore better ways to execute a business process was developed, resulting in an improved (perturbed) event log. Identifying the differences between the original event log and the perturbed event log can provide valuable insights, helping organisations to improve their processes. However, there is a lack of automated techniques to detect the differences between two event logs. Therefore, this research aims to develop visualisation techniques to provide targeted analysis of resource reallocation and activity rescheduling. The differences between two event logs are first identified. The changes between the two event logs are conceptualised and realised with a number of visualisations. With the proposed visualisations, analysts will then be able to identify the changes related to resource and time, resulting in a more efficient business process. Ultimately, analysts can make use of this comparative information to initiate evidence-based BPI activities.

Evaluating and predicting overall process risk using event logs

Companies standardise and automate their business processes in order to improve process eff ciency and minimise operational risks. However, it is di fficult to eliminate all process risks during the process design stage due to the fact that processes often run in complex and changeable environments and rely on human resources. Timely identification of process risks is crucial in order to insure the achievement of process goals. Business processes are often supported by information systems that record information about their executions in event logs. In this article we present an approach and a supporting tool for the evaluation of the overall process risk and for the prediction of process outcomes based on the analysis of information recorded in event logs. It can help managers evaluate the overall risk exposure of their business processes, track the evolution of overall process risk, identify changes and predict process outcomes based on the current value of overall process risk. The approach was implemented and validated using synthetic event logs and through a case study with a real event log.

Neural correlates of semantic priming for ambiguous words: An event-related fMRI study

We investigated the neural correlates of semantic priming by using event-related fMRI to record blood oxygen level dependent (BOLD) responses while participants performed speeded lexical decisions (word/nonword) on visually presented related versus unrelated prime-target pairs. A long stimulus onset asynchrony of 1000 ms was employed, which allowed for increased controlled processing and selective frequency-based ambiguity priming. Conditions included an ambiguous word prime (e.g. bank) and a target related to its dominant (e.g. money) or subordinate meaning (e.g. river). Compared to an unrelated condition, primed dominant targets were associated with increased activity in the LIFG, the right anterior cingulate and superior temporal gyrus, suggesting postlexical semantic integrative mechanisms, while increased right supramarginal activity for the unrelated condition was consistent with expectancy based priming. Subordinate targets were not primed and were associated with reduced activity primarily in occipitotemporal regions associated with word recognition, which may be consistent with frequency-based meaning suppression. These findings provide new insights into the neural substrates of semantic priming and the functional-anatomic correlates of lexical ambiguity suppression mechanisms.