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The aim of this pilot study was to assess whether an acceptance and commitment therapy (ACT) group could benefit the mental health of older adults (aged 65–84) in a community psychiatric setting. Ten older adults participated in a 6-week pilot ACT group (M age = 72 years; seven women). All participants had a diagnosed chronic/recurrent major depressive disorder with a variety of comorbid psychiatric and medical conditions. Participants completed a battery of outcome measures to explore whether the program improved their mental health. Seven out of the 10 participants completed the ACT group pilot. These seven participants showed improvements on the battery of outcome measures from pre to post, including psychiatric symptom severity, mood, subjective health status, values progress, hopefulness, confidence, awareness, and social connectedness. This pilot study provides promising evidence that ACT groups could be a viable adjunct recovery option for older adults receiving community mental health services.

The COVID-19 pandemic has placed significant pressures on healthcare services and professionals delivering patient care. Consequently, postgraduate medical training has been interrupted, with limited opportunities for supervised workplace-based assessments.1 Therefore, additional knowledge and skills gained, particularly those outside the scope of respective training curriculum, may not be robustly captured. This project aimed to identify trainees’ views on additional capabilities gained during the pandemic and the value of self-certification, in order to inform the design of a COVID self-certification template. A SurveyMonkey® questionnaire was emailed to all postgraduate trainees in the East Midlands and Wessex deaneries. The survey was also …

The COVID-19 pandemic has had a huge impact on society, healthcare in general and also on training in surgery. Cancellation of elective procedures, redeployment and establishment of green sites have combined with other factors to create significant gaps in training experience in operative and all other areas of surgery. There are nearly a million cases which have been lost to training since March 2020 and recovery means that tens of thousands of extra training cases have to be performed every month to recover that experience. There are pressures to address huge waiting list backlogs which may squeeze out time for training unless training is considered at the heart of any recovery plan. #NoTrainingTodayNoSurgeonsTomorrow. New, no blame, COVID ARCP outcomes have helped recognise the impact of the pandemic on progression and significant trainee and trainer organisations are united in raising the profile of the training crisis and offering a suite of suggestions on how to speed recovery. Disruption caused by the pandemic has allowed existing simulation and conferencing platforms to finally be widely accepted and the importance of the wider surgical team in supporting surgical training to be realised. New, outcomes based curricula, with better feedback at their centre, will speed recovery of training trajectories. We should embrace the opportunity for change to help short and medium term recovery and improve the delivery of surgical training into the future.

The COVID-19 pandemic has caused significant disruption to patient care delivery and medical training in the UK.1 However, the views of healthcare professionals on the impact of the pandemic has not been fully explored. This study aimed to identify the challenges experienced by healthcare professionals during the COVID-19 pandemic and proffer potential solutions, from the perspectives of postgraduate trainees. A SurveyMonkey® questionnaire was emailed to postgraduate trainees through Health Education England (HEE) deanery databases, to capture their experiences during the pandemic. The survey was also circulated informally via WhatsApp®, to include the views of individuals in non-training posts. Ethics review was …

Objectives: To explore the experiences of older adults who participated in a randomised controlled trial (RCT) that tested cognitive behaviour therapy for insomnia and depression.Methods: Focus gro...

Study Objectives To investigate whether cognitive behavior therapy was effective for older adults with comorbid insomnia and depression in a community mental health setting, and explore whether an advanced form of cognitive behavior therapy for insomnia produced better outcomes compared to a standard form of cognitive behavior therapy for insomnia. Methods An 8-week randomized controlled clinical trial was conducted within community mental health services, Victoria, Australia. Seventy-two older adults (56% female, M age 75 ± 7 years) with diagnosed comorbid insomnia and depression participated. Three conditions were tested using a group therapy format: cognitive behavior therapy for insomnia (CBT-I, standard), cognitive behavior therapy for insomnia plus positive mood strategies (CBT-I+, advanced), psychoeducation control group (PCG, control). The primary outcomes were insomnia severity (Insomnia Severity Index) and depression severity (Geriatric Depression Scale). Primary and secondary measures were collected at pre (week 0), post (week 8), and follow-up (week 20). Results CBT-I and CBT-I+ both generated significantly greater reductions in insomnia and depression severity compared to PCG from pre to post (p < .001), which were maintained at follow-up. Although the differences between outcomes of the two treatment conditions were not statistically significant, the study was not sufficiently powered to detect either superiority of one treatment or equivalence of the two treatment conditions. Conclusion CBT-I and CBT-I+ were both effective at reducing insomnia and depression severity for older adults. Mental health services that deliver treatment for comorbid insomnia with cognitive behavior therapy may improve recovery outcomes for older adults with depression. Trial Registration: Australian and New Zealand Clinical Trials Registry (ANZCTR); URL: https://www.anzctr.org.au; Trial ID: ACTRN12615000067572; Date Registered: December 12, 2014.

Insomnia and depression are two of the most common mental health problems that negatively impact older adults. The burden associated with these highly comorbid conditions requires an innovative approach to treatment. There have been significant advancements in the field of cognitive behaviour therapy for insomnia (CBT-I) over recent years. CBT-I has evolved from targeting homogenous insomnia samples to now showing promising results for comorbid insomnia. CBT-I is not only effective at treating comorbid insomnia, but can also have a positive impact on depression severity. Despite these important clinical developments, limited research has explored whether modifying CBT-I programmes to specifically target comorbid depression could improve outcomes for older populations. This paper reviews recent literature and provides therapeutic recommendations to advance CBT-I for older adults with comorbid insomnia and depression.

Background: Higher levels of insomnia predict greater depression severity among older adults; however, the psychological mechanisms underlying this relationship are unclear. This study tested a path model that explored whether dysfunctional beliefs about sleep and hopelessness mediated the relationship from insomnia to depression. It was hypothesized that insomnia would predict depression, both directly and indirectly, via dysfunctional beliefs about sleep and hopelessness.Methods: A community sample of 218 independent-living Australian older adults aged from 65 to 96 years completed a self-report questionnaire package. From the initial 218 participants, 171 completed a measure of depression three months later.Results: Path analysis demonstrated that maladaptive sleep beliefs and hopelessness partly explained how insomnia influenced depression, irrespective of the presence of obstructive sleep apnea and/or restless legs syndrome.Conclusions: An older adult's beliefs about sleep and sense of hopelessness were important psychological factors that helped explain how insomnia related to depression.

There has been a recent resurgence of interest in the use of human albumin solution (HAS) for the resuscitation of critically ill patients. In particular, it may be beneficial for patients with severe sepsis and septic shock. We outline the evidence for the biological plausibility of this effect, perform a meta-analysis of randomised controlled trials comparing the effect of HAS with other fluid resuscitation on mortality in this group of patients and discuss the likely contribution of recently completed trials in this area. We included nine trials of 1,435 patients in the meta-analysis. Although HAS resuscitation was associated with a trend to lower mortality (relative risk 0.90, 95% confidence interval 0.79–1.02), we found that most trials reported to date are small and of variable methodological quality. The questions of a potential differential effect of dose on outcome and the pharmacological variability of HAS products have not been adequately addressed to date. We conclude that the routine administration of HAS to patients with severe sepsis and septic shock is difficult to justify on the basis of current knowledge.

Although non-invasive ventilation is the mainstay of management for patients with hypercapnic acute exacerbation of COPD, invasive mechanical ventilation (IMV) still has an important role to play. IMV can be used successfully to reduce mortality and still maintain quality of life in a subset of patients. Despite this, the evidence to support which patients will benefit from IMV is limited. This article reviews the literature available to guide clinician decision-making. Age is not a reliable independent predictor of survival for COPD patients receiving IMV, nor are levels of PaO2, PCO2, or use of long-term oxygen therapy. Body composition and nutritional status are independent predictors of survival and the presence of co-morbidities, such as cor pulmonale, cardiovascular disease and diabetes mellitus are negative prognostic indicators. Length of time in hospital prior to ICU admission also is an adverse prognostic factor. Although scoring systems exist, their ability to predict outcome for individual patients has limitations. Work needs to be done to improve end-of-life planning in COPD with the encouragement of discussion about advance directives when patients are reaching advanced stage of the disease.

Functionalised silicas, used for selectively removing metal impurities in process streams, are packed in cartridges and inserted into multicartridge filters. The scavenging step that follows a catalytic reaction involves the single pass of the process stream through the multicartridge filter setup at a predetermined linear velocity and temperature. Efficiency in metal reduction as high as 98% has been so far achieved at tens of kilograms scale. Furthermore, the precious metal anchored onto the scavenger’s functionalities can be recovered and refined. Our chronological development of a versatile, general, and easily scalable format for metal scavenging at process scales is described, illustrated by application in real time to a range of projects passing through our Pharmaceutical Pilot Plant, employing a variety of metals (palladium, rhodium, iridium). Benefits of the cartridge format in terms of economics and environmental impact are also initially assessed.

Postoperative or posttraumatic sepsis remains one of the leading causes of morbidity and mortality in hospital populations, especially in populations in intensive care units (ICUs). Central to the successful control of sepsis-associated infections is the ability to rapidly diagnose and treat disease. The ability to identify sepsis patients before they show any symptoms would have major benefits for the health care of ICU patients. For this study, 92 ICU patients who had undergone procedures that increased the risk of developing sepsis were recruited upon admission. Blood samples were taken daily until either a clinical diagnosis of sepsis was made or until the patient was discharged from the ICU. In addition to standard clinical and laboratory parameter testing, the levels of expression of interleukin-1β (IL-1β), IL-6, IL-8, and IL-10, tumor necrosis factor-α, FasL, and CCL2 mRNA were also measured by real-time reverse transcriptase PCR. The results of the analysis of the data using a nonlinear technique (neural network analysis) demonstrated discernible differences prior to the onset of overt sepsis. Neural networks using cytokine and chemokine data were able to correctly predict patient outcomes in an average of 83.09% of patient cases between 4 and 1 days before clinical diagnosis with high sensitivity and selectivity (91.43% and 80.20%, respectively). The neural network also had a predictive accuracy of 94.55% when data from 22 healthy volunteers was analyzed in conjunction with the ICU patient data. Our observations from this pilot study indicate that it may be possible to predict the onset of sepsis in a mixed patient population by using a panel of just seven biomarkers.

Cognitive behaviour therapy for insomnia (CBT-I) is a well-established treatment; however, the evidence is largely limited to homogenous samples. Although emerging research has indicated that CBT-I is also effective for comorbid insomnia, CBT-I has not been tested among a complex sample of older adults with comorbid insomnia and depression. Furthermore, no study has explored whether modifying CBT-I to target associated depressive symptoms could potentially enhance sleep and mood outcomes. Therefore, this study aims to report a protocol designed to test whether an advanced form of CBT for insomnia and depression (CBT-I-D) is more effective at reducing insomnia and depressive symptoms compared to a standard CBT-I and psychoeducation control group (PCG) for older adults in a community mental health setting. We aim to recruit 150 older adults with comorbid insomnia who have presented to community mental health services for depression. Eligible participants will be randomly allocated via block/cluster randomisation to one of three group therapy conditions: CBT-I, CBT-I-D, or PCG. Participants who receive CBT-I will only practice strategies designed to improve their sleep, whereas participants who receive CBT-I-D will practice additional strategies designed to also improve their mood. This trial will implement a mixed-methods design involving quantitative outcome measures and qualitative focus groups. The primary outcome measures are insomnia and depression severity, and secondary outcomes are anxiety, hopelessness, beliefs about sleep, comorbid sleep conditions, and health. Outcomes will be assessed at pre-intervention (week 0), post-intervention (week 8), and 3-month follow-up (week 20). This CBT study protocol has been designed to address comorbid insomnia and depression for older adults receiving community mental health services. The proposed trial will determine whether CBT-I is more effective for older adults with comorbid insomnia and depression compared to a PCG. It will also establish whether an advanced form of CBT-I-D generates greater reductions in insomnia and depression severity compared to standard CBT-I. The results from the proposed trial are anticipated to have important clinical implications for older adults, researchers, therapists, and community mental health services. Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN: 12615000067572 , Date Registered 12 December 2014.

Community Aged Intensive Recovery (CAIR) programs are an integral part of Aged Persons Mental Health Services (APMHS); however, no study has investigated whether a rural-based intensive program benefits older clients with severe mental illness. The current sample comprised 119 older adults who were being managed by a CAIR program from July 2011 to June 2013. Three key results were found: (a) approximately three quarters of clients admitted to the CAIR program remained treated in the community; (b) the program assisted in significantly reducing the level of psychiatric symptom severity from CAIR entry to CAIR exit; and (c) the APMHS team with the CAIR program had a lower psychiatric inpatient rate compared to the APMHS team without the program. The current study highlights the importance of delivering effective rural-based CAIR programs to older adults experiencing severe mental illness. [ Journal of Psychosocial Nursing and Mental Health Services , 53 (9), 17–21.]

Recognition of venous thromboembolism (VTE) depends on clinical suspicion, implementation of a scoring algorithm and (where indicated) a D-dimer assay. Treatment consists of support and anitcoagulation to reduce the risk of extension. Effective prophylaxis in appropriate groups is the most effective way of reducing morbidity from VTE. For prophylaxis, low molecular weight heparins (LMWHs) are as effective at preventing VTE as unfractionated heparin, with the advantages of once-daily administration, fewer side effects and no requirement for monitoring activated partial thromboplastin time. Neuraxial block following the administration of LMWH may give rise to significant complications.

The development of two efficient strategies for the synthesis of AZD4407 is reported, both of which are considered suitable for large-scale manufacture. In the first approach, 3-bromothiophene is coupled with (2S)-2-methyltetrahydropyran-4-one using Grignard chemistry. Following hydroxyl protection and lithiation at thiophene C-2, reaction with a protected 5-mercapto-1-methyl-1,3-dihydro-indol-2-one derivative bearing a leaving group on sulphur provides AZD4407 after acid-catalysed deprotection and epimerisation. The second approach starts from 2,4-dibromothiophene, which undergoes a selective Grignard exchange reaction at C-2 followed by reaction with similar protected mercapto-oxindole derivatives. Reprotection of the oxindole ring, followed by a second Grignard exchange, and reaction with (2S)-2-methyltetrahydropyran-4-one provides AZD4407 after acid-catalysed deprotection and epimerisation.

Recognition of venous thromboembolism (VTE) depends on clinical suspicion, implementation of a scoring algorithm and (where indicated) a D-dimer assay. Treatment consists of support and anitcoagulation to reduce the risk of extension. Effective prophylaxis in appropriate groups is the most effective way of reducing morbidity from VTE. For prophylaxis, low molecular weight heparins (LMWHs) are as effective at preventing VTE as unfractionated heparin, with the advantages of once-daily administration, fewer side effects and no requirement for monitoring activated partial thromboplastin time. Neuraxial block following the administration of LMWH may give rise to significant complications.

Henoch-Schonlein purpura (HSP) is a multisystem disorder characterised by systemic vasculitis involving small vessels. We report a case of an 18 year-old male with HSP who survived after a prolonged stay on intensive care. In addition to problems of glomerulonephritis and intussusception, he became seriously compromised by decreased left ventricular function and pulmonary haemorrhage which are rare in this disease 1-2 . Treatment interventions included aggressive immunosuppression (used for the management of pulmonary haemorrhage in previous case reports), immunoglobulin therapy and plasma exchange, the combination of which may have been instrumental in the positive outcome in this case.

There has been little research in Australia on the effectiveness of various interventions in cases of elder abuse and neglect. Overseas (particularly US) studies have identified four main types of intervention: (1) assessment; (2) casework; (3) legal interventions; and (4) development of social policies to address the causes of abuse and neglect. This article reviews the findings on effective intervention strategies. Particular attention is paid to the findings of recent research by the Hornsby Ku-ring-gai Geriatric & Rehabilitation Service, especially interviews with victims of elder abuse. The implications for individual casework and future research are highlighted.

Declining length of stay of older people in hospital has caused concern about shifting of costs from acute to community care services. Because the two types of care are funded through different programs and from different jurisdictions, the coordination of acute and post-acute care has become the major issue. There is, however, little information available on patterns of use and costs of post-acute care either in Australia or elsewhere. In an existing longitudinal community study of older people in Dubbo, New South Wales, data on use of services by people aged 60 years and over for 12 months of hospitalisations was collected by linkage to the records of Home and Community Care providers. Only a quarter of older people received any type of Home and Community Care service in the 12 weeks after discharge and two-thirds of these received only one type of service. While less than 5 per cent received a service from an occupational therapist, physiotherapist or speech therapist, 78 per cent visited a general practitioner after discharge. The average cost of all Home and Community Care services received after hospital discharge was around $12.50 per week per person discharged. The predictors of higher costs of service use were: living alone, and the interactions of high levels of disability with owning a house. Results on service coordination, the identification of post-acute services, cost consequences of program funding, assessment and discharge planning are related to debates emerging from the Commonwealth Heads of Government.

Dr Paul Sadler takes another point of view and describes the successful division of his housing-estate practice into four specialist departments: pxediatrics, geriatrics, obstetrics and general medicine. He further details the organization and advantages of his own department, pediatrics.

The crime of arson is an extraordinarily complex one by its definition alone. Its complexity makes many difficulties to the student. It also gives the perpetrator some advantages. To begin with, arson, like murder and most admirality crimes, exists in several degrees of indictment. These degrees are wholly dependent upon the type and use of the structure or property burned, degree of involvement of participants, and often the time of day in which the crime is committed.' But what degrees now exist are only created by modern statutory definition over and above the original common law of England, which law, in comparison with 20th century statutes, seems very defective in scope. Yet the need for a wide and broad coverage in the protection from arson has only recently, in terms of the history of English and American law, been necessary at all. Why? The reason is that originally English common law defined and limited the crime of arson only to the malicious burning of the dwelling house of another. Note the restrictions of the words "dwelling" and "another." The common law clearly was aimed at, first, assuring the security of habitation, and secondly, at assuring the security of habitation of all the general public with the exception of the dwelling house of one's self. Curtis writes, "Using the language of Sir William Blackstone, 'Arson, ab ardendo, is the malicious and willful burning of a house or outhouse of another man.' Sir Edward Coke had, before the time of Blackstone, expressed his conception of arson as 'the malicious and voluntary burning the house of another by night or by day.' The courts, when seeking a definition of common law arson, have generally adopted that of Blackstone, declining to include the redundancy 'by night or by day.' Other definitions make a slight variation in language, but no change in substance, has occurred. Thus the offense has been defined as 'the malicious burning of another's house'; or as the 'willful and malicious burning of the dwelling house of another'; or as 'the volun