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Prompt recognition of frailty in the emergency department (ED) is important to identify patients at higher risk of adverse outcomes. Despite this, few studies examine the diagnostic accuracy of screening instruments for frailty, instead focusing on predictive validity. We compared three commonly used, short frailty screens to an independent comprehensive geriatric assessment (CGA) in an urban University Hospital ED. Consecutive attendees aged ≥70 years were screened by trained raters, blind to the CGA, with the Variable Indicative of Placement risk (VIP), 3 and 4-item versions, Clinical Frailty Scale (CFS) and PRISMA-7. Accuracy was measured from the area under the ROC curve (AUROC). In total, 197 patients were included, median age 79 (±10); 46% were female. Half (49%) were confirmed as frail after CGA. All instruments differentiated frail from non-frail states, although the CFS (AUROC: 0.91) and PRISMA-7 (AUROC: 0.90) had higher accuracy compared to the VIP-4 (AUROC: 0.84) and VIP-3 (AUROC: 0.84). The CFS was significantly more accurate than the VIP-3 (p = 0.026) or VIP-4 (p = 0.047). There was no significant difference between the CFS and PRISMA-7 (p = 0.90). The CFS and PRISMA-7 were more accurate and should be considered in preference to the VIP (3 or 4-item versions) to identify frailty in EDs.

Background Urinary incontinence (UI) is defined by the International Continence Society as “any involuntary leakage of urine.” UI can negatively impact patients' physical and mental wellbeing and quality of life. Since older adults constitute a growing hospital population, evaluation and improvement of this patient group's quality of care is recognized as a priority in the study hospital. A continence assessment helps to determine what the problem is and what management is required. This audit aims to determine whether appropriate assessments of continence in older adults presenting to the hospital setting were completed and documented. Methods An audit tool was adapted from the Royal College of Physicians National Continence Audit tool and the hospital's own elimination documentation pathway. On a chosen day a general medical ward and a specialist geriatric medicine ward were assessed. Medical charts, nursing notes, emergency department proforma, frailty intervention team proforma and skin integrity proforma were reviewed. Documentation of continence status, symptoms, type, investigations, continence wear, catheterisation and management were assessed. Continence care plans and evidence of communication/discussion with patients were also assessed. Results Thirty-one sets of documentation were reviewed. Twenty-four patients were aged over 65. Of these patients 12 were male and 12 were female. Four patients had no continence status documented. Forty-two percent of those reviewed over 65 had documented incontinence and of these only 40% had the elimination section of their nursing proforma fully completed. Six of the patients with documented incontinence had their symptoms/type of incontinence documented. Two Patients had urinary catheters, the indications for these catheters were documented Conclusion This audit found that overall the assessment and documentation of continence in older adults was sub-optimal. Based on this audit an assessment tool and education program will be introduced to the specialist geriatric medicine ward with the goal of improving assessment of continence and optimal management.

Background For many people an admission to an acute hospital can be a stressful and overwhelming experience. During admission it can be difficult to process and understand the information provided by members of the multi-disciplinary team (MDT). Patient information leaflets (PILS) are important in educating and empowering patients in the management of their own health and wellbeing. PILs are frequently provided to patients by MDT members during their admission. These valuable resources are not always consulted by patients or their families and in many cases are not brought home from hospital. Methods Using Plan Do Study Act (PDSA) methodology patient information folders named “My healthcare information” were provided to in-patients by MDT members. Patients were encouraged to put all PILs provided by the MDT in these folders and bring them home for future reference. Questionnaires were administered to patients to ascertain if they found the folders useful and would be likely to use them going forward. Two PDSA cycles have been completed to date. Results ​The results were largely positive. A significant amount of those questioned found it difficult to understand and remember what was said to them by hospital staff (5 of 15 respondents or 33%) and felt they did not receive enough written information about their condition (6 of 15 respondents or 40%). A high proportion of those asked stated they found the folder useful and would be likely to use it at home going forward (22 of 23 respondents or 96%). Conclusion My healthcare information folders are a potentially useful tool in empowering patients and educating them about their own health and wellbeing. Further PDSA cycles and staff education is required to continue the project. The next PDSA cycle will focus on the MDT member’s experience of using the folders.

With this editorial I am happy to introduce the first issue of the second volume of the ARISE Journal. The purpose of this editorial is to briefly discuss authentic or ‘real-world’ science, its place in society, in the classroom and how it can support and explicitly link to students’ perception of scientific careers and potentially enhance uptake of science subjects.

Background It is reported that more than 128 million patients are seen in emergency departments (EDs) annually. Patient overcrowding had been associated with an increased occurrence of medication errors. Purpose Due to increased patient volume and the need for improved patient safety, a 24-hour pharmacy service was established for our institution's ED. The purpose of the study is to quantify and demonstrate the impact of a 24-hour pharmacy service in an urban ED. Methods This was a retrospective descriptive study conducted at a regional level 1 trauma center. The study period occurred between December 2012 and July 2013. The following variables were quantified and analyzed: number of medication orders reviewed, number of intravenous medications compounded, and number of clinical interventions that were recommended by the ED pharmacy team (EDPT) and accepted by ED clinicians. Results A total of 3,779 medication orders were reviewed by the EDPT. Of these orders, 3,482 (92%) were prospectively reviewed. A total of 3,068 (81.2%) and 711 (18.8%) orders were reviewed for the adult and pediatric ED, respectively. During the study period, the EDPT procured 549 intravenous admixtures and conducted 642 clinical interventions. Most of the interventions involved providing drug information for physicians and nurses (45.9%), adjusting drug dosages (21.1%), and recommending antimicrobial therapy (15.1%). Conclusion The implementation of a 24-hour pharmacy service at our institution was an innovative practice that increased the role of pharmacists in the ED. The EDPT conducted prospective medication review, procured intravenous admixtures from a sterile environment, and provided therapeutic recommendations for the ED interdisciplinary team.

In the Summoner's Tale Chaucer presents a satirical portrait of a glutton- ous friar who—to put it bluntly—spreads the Word as a means of enhancing his own flesh. Friar John's sermon to his lay charge Thomas, an excessive performance that consumes more than half of the tale, shows that he preaches in order to get donations from lay people and, more broadly, to exert his authority over them. As has often been noted, Friar John's preaching style reveals his particular affection for glossing, a form of scriptural interpretation that, according to the friar, compen- sates for the comprehension problems that will indubitably confront his lay audience. 1 The friar thus evokes late fourteenth- and early fifteenth- century debates on scriptural glossing and vernacular translation, prac- tices that, in accommodating popular understanding, seemed to entail a loss of clerical control over sacred texts. 2 Although Friar John speaks to these medieval lay-centered initiatives, he himself does not gloss to enable lay access to scriptural meaning but rather to secure his clerical power, which is evident, for instance, in his appeal to a nonexistent scrip- tural passage that contains Christ's special blessing of friars. 3 Scriptural interpretations meant to sanction the friar's own authority pervade his sermon to Thomas, who responds by presenting Friar John with an equally illustrious, if vulgar, gift. Thomas's donation, a fart delivered into the friar's hand, has inspired a great deal of scholarship, some of which has regarded it as an echo of the friar's own long-winded performance. 4 Following this critical impulse to read the fart as a defiant response to the friar's sermon, I consider what else their exchange discloses about how clerical and lay subjects speak, hear, and control sacred discourse. In this essay I contend that the Summoner's Tale reflects Chaucer's investment in representing sacred verbal performances, which perhaps is most obvious in the friar's self-serving sermon yet also apparent in the tale's allusions to a specific type of medieval devotional ritual: eucharistic prayers. To understand the significance of Chaucer's refer- ences to eucharistic prayers in the Summoner's Tale, we must first acknowledge how they were performed in the medieval liturgy. From

This qualitative study has been designed to examine chronic sorrow in a population of individuals with type 1 diabetes. Teel1 defines chronic sorrow as ‘a recurring sadness interwoven with periods of neutrality; satisfaction and happiness’. The sample chosen are five adult subjects with type 1 diabetes for an average of 22.4 years. Data was collected using audio taped, semi-structured, interviews. Tapes were transcribed and analysed. Four themes emerged; fear of the future, negative attitudes of others, regrets and difficulties in managing the condition. The study discusses the causes of sadness. Results are of relevance to people with diabetes, and those who care for them. Copyright © 2001 John Wiley & Sons, Ltd.

If the underlying problem is really underfunding, then making these issues explicit can only contribute to a better informed debate about the proportion of GNP which is allocated to health care.37 Managing underfunding by making hidden and possibly ill-informed calculations about who shall live and who shall die on criteria which are not purely clinical, and which are therefore outside both the competence and the legitimacy of the doctor, is not an answer to the question. It might usefully be asked whether classiifying decisions in this area as 'medical law' and as part of some emerging body of medical jurisprudence actually helps or hinders the cause of getting the issues into the public domain. If there is such a thing as medical law, it has not so far succeeded in elaborating the circumstances in which health authorities should be accountable, in a public law sense, for spending and allocation decisions. Requiring health authorities to give reasons for their decisions and to show that they have engaged in a rational process in precisely the same way that we require of other public bodies would better enable us to establish, first, the extent to which they have or have not reached a decision which no reasonable authority could have reached and, secondly, the extent to which we should recognise any special claims or limitations resulting from the particular ethical dilemmas which they face.

Objective : Screening incarcerated populations, particularly men who have sex with men (MSM), for the identification, treatment, and prevention of sexually transmitted infections (STI) and HIV provides an effective way to access a hard-to-reach, high-risk population. Goal : To describe findings from a screening program designed to identify STIs and HIV among incarcerated MSM. Study design : The Los Angeles County Sexually Transmitted Disease Program implemented a voluntary HIV and STI screening program in the segregated MSM unit of the Los Angeles County Men's Jail in March 2000. This analysis reports on data collected through December 2005. Results : Between March 2000 and December 2005, a total of 7004 inmates participated in the screening program. The overall positivity rate for chlamydia was 3.1% (127 of 4157) and 1.7% (69 of 4106) for gonorrhea. In addition, early syphilis was identified in 1.6% of inmates (95 of 6008) and the overall prevalence of HIV was 13.4% (625 of 4658). The level of repeat testing was relatively high with 15% (1048) of inmates repeatedly incarcerated and screened for STIs over the 5-year period. Although the seroprevalence of HIV was not significantly different between repeaters and nonrepeaters, 33 inmates were HIV seropositive after having tested negative at prior bookings, resulting in an HIV incidence of 1.9%. Conclusions : Screening incarcerated MSM in Los Angeles revealed a high prevalence of STI and HIV infection. These inmates not only represent a high-risk group, but also a unique opportunity for the identification, treatment, and counseling of this hard-to-reach, high-risk population.

The enactment of the Children Act 1989 brings to an end one major piece of family law reform in which the Law Commission played a leading role. The publication of the Commission's discussion paper on the Ground for Divorce in 1988 is a first stage in an equally fundamental review, the outcome of which must have profound implications for many aspects of family law. In publishing its Working Paper on Domestic Violence and Occupation of the Family Home the Commission seems to have acted in the belief that they were addressing a discrete topic which could usefully be considered in isolation from some more fundamental issues. Perhaps this belief explains why the Working Paper is in some respects flawed. The aim of the Law Commission was not to propose major changes in the present law as to domestic violence and occupation of the family home, but rather to put forward a system of unified remedies, to produce 'a single set of remedies which could be made available in all courts and all family proceedings'.2 Under the existing scheme, jurisdiction is divided between the High Court, county courts and magistrates' courts, and is derived from several different pieces of legislation; so there is evident fragmentation which quite properly attracted the Commission's attention. It is important to note two features of the present law. First, in the High Court and the county courts, remedies for domestic violence and the regulation of the occupation of the family home are run together. Jurisdiction rests on the Matrimonial Homes Act 1983 and the Domestic Violence and Matrimonial Proceedings Act 1976, and in consequence of the decision of the House of Lords in Richards v Richards3 the criteria in section 1(3) of the 1983 Act are of general relevance. In the magistrates' courts, the jurisdiction under the Domestic Proceedings and Magistrates' Courts Act 1978 is violence based. This prompted the Law Commission, in considering a unified scheme, to suggest the enlargement of the magistrates' jurisdiction. Second, under the Domestic Violence and Matrimonial Proceedings Act 1976, the same remedies are available in the county court to cohabitees as are available to spouses.4 As a result, the Working Paper frequently addressed the position of both without distinguishing between them. However, it then had to ask whether, under a unified system, magistrates should have the power to regulate, enforce or grant rights of occupation in the case of cohabitees.5 The Commission's concern to create a unified system of remedies obscures the policy issues underlying some key distinctions. One is the distinction between, on the one hand, cases of violence and threatened violence and, on the other, cases where a marriage is in the process of breaking down. Violence needs an urgent and strong response, whereas the question of occupation of the family home on relationship breakdown lacks that urgency, and raises quite different policy issues. Unified treatment of the occupation rights of spouses

Background Increasing availability of urine testing for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) offers expanded opportunities to collaborate with community-based organizations (CBOs) to screen high-risk populations for sexually transmitted diseases (STDs). Goal To determine the prevalence and correlates of genital tract gonococcal and chlamydial infection among CBO clients, and to assess the feasibility of implementing widespread community-based STD screening programs. Design Free, voluntary, confidential first-catch urine screening was conducted at 20 CBOs serving disadvantaged populations in St. Louis, MO. Brief demographic, behavioral, and sexual contact data were obtained from all participants. Urine samples were tested by ligase chain reaction (LCR). Persons testing positive were promptly notified and directed to seek treatment. Results A GC and/or CT infection was identified in 24 of 277 persons (8.7%) screened; 2 persons were infected with GC only, 17 with CT only, and 5 with GC and CT. Treatment was documented for 22 persons (91.7%) testing positive. The highest rates of infection were found at shelters (12.3%) and residence facilities (11.1%). Costs of screening were $38 per sample collected and $453 per case identified. Conclusion Community-based urine testing successfully identified GC and CT infections, and was well accepted by community members and CBOs. Community-based screening can significantly impact STD epidemiology by facilitating early detection, treatment, and interruption of transmission.