Purley War Memorial Hospital

Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist.

Background: Primary progressive aphasia (PPA) is a clinical dementia syndrome characterised by the gradual dissolution of language without impairment of other cognitive domains for at least the first 2 years of illness (Mesulam, 2001 Mesulam, M. M. 2001. Primary progressive aphasia.. Annals of Neurology, 49: 425–432. [Crossref], [PubMed], [Web of Science ®] , [Google Scholar]). In recent years the authors had observed an increase in the number of referrals of individuals with a queried diagnosis of PPA to their speech pathology service. However, they perceived a lack of information on the best management path for these individuals. Aims: The aim of this study was to collate information about current service provision for clients with PPA living in the Australian state of New South Wales (NSW) and their caregivers. This information would identify current referral rates and speech pathology management of this population. This information, when combined with a review of the literature and an examination of overseas service provision, would be used to develop a framework for future speech pathology service provision for progressive aphasia. Method & Procedures: Data relating to individuals with queried or confirmed PPA was collected from speech pathologists via a survey. Speech pathology services with an adult neurological caseload were surveyed in rural and metropolitan regions across NSW. Questions asked for information relating to referral patterns, demographics, and interventions provided. Outcomes & Results: Responses from the survey indicated that only a small number of clients with PPA are referred to speech pathologists state‐wide. At facilities where individuals were referred with queried PPA, all respondent speech pathologists provided some form of intervention. All clients were assessed and various intervention types were delivered including individual therapy, group therapy, intermittent review, and client and carer education. Overwhelmingly respondents talked of an emerging field of practice, and the need for more accessible information for clinicians and people with PPA and their carers. Conclusion: PPA appears to be an area of under‐referral for speech pathologists in NSW. We would like to see increased referrals to speech pathology services and promotion of the role of the speech pathologist on dementia care teams. There is evidence that speech pathology intervention with this population can be effective. It is recommended that intervention targets both impairment and activity‐participation levels but also we stress the importance of education and support that is specifically tailored to those with progressive language disorders.

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

A recent study of the physiology of flow through the sphincter of Oddi (Wyatt, 1967) indicated that amongst other factors gastric peristalsis was related to changes of resistance at the sphincter.This was especially notable when food was present in the stomach.Electrical stimuli leading to contraction of the gastric antrum often resulted in relaxation of the sphincter with increased flow through it.This relationship did not depend on extrinsic nervous connexions and was therefore supposed to depend on the continuity of smooth muscle of the stomach, duodenum, and sphincter of Oddi, or on the intrinsic nerve plexus of the bowel in this region.This raises the question as to what effect, if any, there is on bile flow when the stomach is disconnected from the duodenum as in a Polya type of gastrectomy.Further experiments are now reported which show that there are changes in biliary flow and pressure patterns after this type of operation.

Cognitive interventions, including cognitive stimulation therapy, cognitive rehabilitation and cognitive training, are increasingly recommended as key components of non-pharmacological post-diagnostic support for people with dementia. Cognitive interventions may help delay cognitive decline, enhance goal-directed functional abilities and improve quality of life. Despite inclusion in clinical guidelines and recommendations, guidance on the delivery of these interventions within Australian community settings remains limited and is underutilised. This article addresses a critical translation gap in cognitive interventions for people with dementia, synthesises the evidence through an Australian practice and policy lens, examines current uptake in community settings and identifies barriers, enablers and delivery models to inform implementation strategies. Community settings are defined as memory clinics, primary care, hospital outpatient services, allied health providers, community aged care and non-government providers. Current evidence indicates cognitive interventions have varying benefits across different outcomes, including cognitive function, social engagement, everyday functioning, quality of life and goal attainment. International practices related to implementation are explored, along with future directions for expanding access through technology, flexible delivery models, group-based approaches and integrating these interventions into existing care structures. Addressing the gap between recommendations and current practices requires building community awareness, improving access to professional education and training, and careful resource allocation. Cognitive interventions should be part of comprehensive rehabilitation and can be personalised to individual needs and goals. Expanding access and improving the availability of a range of cognitive interventions in community settings is crucial to ensure people with dementia receive best practice post-diagnostic support.

BACKGROUND: Elder abuse often goes unreported and undetected. Older people may be ashamed, fearful, or otherwise reticent to disclose abuse, and many health providers are not confident in asking about it. In the No More Shame study, we will evaluate a co-designed, multi-component intervention that aims to improve health providers' recognition, response, and referral of elder abuse. METHODS: This is a single-blinded, pragmatic, cluster randomised controlled trial. Ten subacute hospital sites (i.e. clusters) across Australia will be allocated 1:1, stratified by state to a multi-component intervention comprising a training programme for health providers, implementation of a screening tool and use of site champions, or no additional training or support. Outcomes will be collected at baseline, 4 and 9 months. Our co-primary outcomes are change in health providers' knowledge of responding to elder abuse and older people's sense of safety and quality of life. We will include all inpatients at participating sites, aged 65 + (or aged 50 + if Aboriginal or Torres Strait Islander), who are able to provide informed consent and all unit staff who provide direct care to older people; a sample size of at least 92 health providers and 612 older people will provide sufficient power for primary analyses. DISCUSSION: This will be one of the first trials in the world to evaluate a multi-component elder abuse intervention. If successful, it will provide the most robust evidence base to date for health providers to draw on to create a safe environment for reporting, response, and referral. TRIAL REGISTRATION: ANZCTR, ACTRN12623000676617p . Registered 22 June 2023.

The Mini-Mental State Examination (MMSE) is one of the most commonly used instruments to screen for cognitive deficits within the hospital setting. However training in how to administer this widely used tool is scarce with little, if any, formal training for nursing staff. Scores are also often misused with over reliance on results and cut-offs to support a diagnosis of dementia within the acute and sub-acute aged care context. The present study assessed the level of training and accuracy in administering the MMSE within a geriatric in-patient rehabilitation ward. Ratings of the level of knowledge, training and confidence in administering the MMSE were obtained from 16 registered nurses and two medical officers before and after an education session on the uses of the MMSE and correct administration. Objective assessment of competencies in administration was also obtained with interrater reliability scores demonstrating high accuracy in the use of this screening instrument. Knowledge improved following the training session, but confidence scores remained unchanged. Results also indicated limited knowledge regarding the necessity for cognitive screening in an aged care setting. Inconsistency in administration of certain items was also identified as a concern. Strategies for improving the quality of administration are identified and discussed.

Background: integrated Rehabilitation and EnAblement Program (iREAP) is an innovative redesign of the traditional day rehabilitation model, providing an anticipatory, early assessment and intervention program that manages care of community-dwelling older people with complex needs. It coordinates access to disciplines across medical, allied health and nursing, with a self-management focus, partnering with primary health in an integrated approach. Objective: This observational study reviews the effectiveness of iREAP on frailty, patient activation, quality of life and physical outcome measures on older people at risk of, or experiencing falls and frailty, or with neurodegenerative conditions, including Parkinson's Disease. Methods: 99 participants completed the eight-week multidisciplinary program. Patient outcome measures included Rockwood Clinical Frailty Scale, quality of life measures, Patient Activation Measure, Timed Up and Go, 6 Minute Walk Test and Berg Balance Scale. Results: On completion of iREAP, participants displayed improvements in their Rockwood Clinical Frailty Scores (mildly frail to vulnerable), 'patient activation' (55.08 to 60.61), quality of life (Parkinson's Disease Questionnaire-39, 49.93 to 47.16; WHO Quality of Life - Bref physical domain, 21 to 22.7) and physical measures including balance (44 to 49/56 Berg Balance scale) and mobility (294 m to 336 m, 6-minute walk test). Falls were not reduced at twelve months post-program (3.40 to 2.01). Conclusion: iREAP is an interdisciplinary, early assessment and intervention program with the potential to reverse frailty and improve quality of life for complex older patients. This paper offers a platform for future research, given the paucity of evidence reviewing the efficacy of integrated anticipatory models of care in older adults with complex needs.

INTRODUCTION: To meet older people's physical and mental health needs the built environment is becoming increasingly important for the health and community aged care systems. The usage of an age-friendly outdoor space as an enhancement to standard treatment for rehabilitation in hospital settings holds promise as part of patients' continuum of care. This descriptive case study described the design and development of an age-friendly outdoor rehabilitation space in a hospital setting in Sydney Australia, the OASIS (Outdoor Activity Space for Improving your Strength) program. METHOD: This descriptive case study reports the step-by-step process from initial concept to activation of the space. Drawing on internal planning documents, site plans, meeting records, and project materials, it outlines key phases including stakeholder consultation, site selection, design development, equipment installation, staff training, risk management, and pilot testing of a group-based exercise program. RESULTS: The process took approximately four years which included consultation, examination and selection of suitable feature design and equipment selection. Training and upskilling staff and risk management were undertaken prior to pilot testing an exercise program. Preliminary usage testing of the space demonstrated safe usage by older people in a group setting with successful transition from supervised program into independent usage. CONCLUSION: The OASIS approach offers an innovative adjunctive therapeutic approach to standard treatment for rehabilitation and physical activity participation of older people in out-patient settings. Future work is required to explore its provisional integration as part of the hospital in-patient and out-patient services.

Backgrounds & aims: Primary biliary cholangitis (PBC) is a chronic liver disease in which autoimmune destruction of the small intrahepatic bile ducts eventually leads to cirrhosis. Many patients have inadequate response to licensed medications, motivating the search for novel therapies. Previous genome-wide association studies (GWAS) and meta-analyses (GWMA) of PBC have identified numerous risk loci for this condition, providing insight into its aetiology. We undertook the largest GWMA of PBC to date, aiming to identify additional risk loci and prioritise candidate genes for in silico drug efficacy screening. Methods: We combined new and existing genotype data for 10,516 cases and 20,772 controls from 5 European and 2 East Asian cohorts. Results: We identified 56 genome-wide significant loci (20 novel) including 46 in European, 13 in Asian, and 41 in combined cohorts; and a 57th genome-wide significant locus (also novel) in conditional analysis of the European cohorts. Candidate genes at newly identified loci include FCRL3, INAVA, PRDM1, IRF7, CCR6, CD226, and IL12RB1, which each play key roles in immunity. Pathway analysis reiterated the likely importance of pattern recognition receptor and TNF signalling, JAK-STAT signalling, and differentiation of T helper (TH)1 and TH17 cells in the pathogenesis of this disease. Drug efficacy screening identified several medications predicted to be therapeutic in PBC, some of which are well-established in the treatment of other autoimmune disorders. Conclusions: This study has identified additional risk loci for PBC, provided a hierarchy of agents that could be trialled in this condition, and emphasised the value of genetic and genomic approaches to drug discovery in complex disorders. Lay summary: Primary biliary cholangitis (PBC) is a chronic liver disease that eventually leads to cirrhosis. In this study, we analysed genetic information from 10,516 people with PBC and 20,772 healthy individuals recruited in Canada, China, Italy, Japan, the UK, or the USA. We identified several genetic regions associated with PBC. Each of these regions contains several genes. For each region, we used diverse sources of evidence to help us choose the gene most likely to be involved in causing PBC. We used these 'candidate genes' to help us identify medications that are currently used for treatment of other conditions, which might also be useful for treatment of PBC.

Alzheimer's dementia (AD) predominantly affects women, and it has no cure when it becomes established.As the current biggest killer of women in the United Kingdom, it became incumbent to explore all preventive strategies.Based on the knowledge that Alzheimer's dementia is homed in the hippocampus and that this area is suffused with estrogen receptors, we explored whether there was a link that might suggest therapeutic or preventive strategies.We found that there was evidence that the hippocampus, the primary area of the brain that we used for declarative memory became deplete with estrogen receptors in the menopause.We also found other pointers which included that hippocampal pathology is central to the development of AD and that the hippocampal shape and volume can predict the onset of AD.There were further of in-vitro and in-vivo support that peri-menopausal estrogens could reduce the incidence of AD in women by up to 35%.

BACKGROUND: We assessed the cost-benefit of person-centered care education for direct care staff of an Australian subacute rehabilitation hospital, with respect to clinical outcomes and service costs of persons with dementia. METHODS: In a nonrandomized pre/post/follow-up design, clinical outcomes and service use were evaluated for matched comparison (n=77) and intervention (n=80) groups for delirium incidence, accidents/injuries, injury treatment, psychotropic medicines, length of stay, hospital readmissions and discharge destination. Group-level outcomes were monetized and included in a cost-benefit analysis (present value of benefits/present value of education and service costs). RESULTS: Relative to the comparison group, there were significant reductions in intervention group delirium (P=0.001), accidents/injuries (P=0.007), treatment for injuries (P=0.007), psychotropic medicines (P=0.030) and hospital readmission within 30 days (P=0.002). After adjusting for the longer length of stay of the intervention subgroup who contracted COVID-19 (n=10), there were no group differences in length of stay (P=0.83). Per participant service costs for comparison and intervention groups were AU$34,870 and AU$33,969, respectively, equating to a per-participant cost saving of AU$914 (P<0.0001). CONCLUSION: Investment in person-centered care education of direct care staff is warranted from both clinical and economic perspectives.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

When a woman consults a doctor about Hormone Replacement Therapy (HRT), the first concern is that there is an increased risk of breast cancer with HRT. And this sole reason might be the reason for refusing the offer of HRT. However, this practice has minimal basis and evidence to support it. Although HRT is an umbrella term, women who have no uterus receive oestrogen-only HRT or Estrogen Replacement therapy (ERT). No valid study has linked ERT with an increased risk of breast cancer [1,2].