Furness College

Cognitive frailty (CF) is the conjunction of cognitive impairment without dementia and physical frailty. While predictors of each element are well-researched, mechanisms of their co-occurrence have not been integrated, particularly in terms of relationships between social, psychological, and biological factors. This interdisciplinary scoping review set out to categorise a heterogenous multidisciplinary literature to identify potential pathways and mechanisms of CF, and research gaps. Studies were included if they used the definition of CF OR focused on conjunction of cognitive impairment and frailty (by any measure), AND excluded studies on specific disease populations, interventions, epidemiology or prediction of mortality. Searches used Web of Science, PubMed and Science Direct. Search terms included “cognitive frailty” OR ((“cognitive decline” OR “cognitive impairment”) AND (frail*)), with terms to elicit mechanisms, predictors, causes, pathways and risk factors. To ensure inclusion of animal and cell models, keywords such as “behavioural” or “cognitive decline” or “senescence”, were added. 206 papers were included. Descriptive analysis provided high-level categorisation of determinants from social and environmental through psychological to biological. Patterns distinguishing CF from Alzheimer’s disease were identified and social and psychological moderators and mediators of underlying biological and physiological changes and of trajectories of CF development were suggested as foci for further research.

Botanic gardens and arboreta are amongst our most loved public spaces. There are over 2500 botanic gardens and arboreta across the world visited by an estimated half a billion people each year. In addition to their cultural value, botanic gardens and arboreta undertake world‐leading scientific research to address global challenges. This virtual issue highlights key articles that feature research linked to the work of botanic gardens, arboreta and herbaria. The papers give a sense of the diverse research endeavours of these institutions, from evaluating biodiversity loss, and conservation of critically endangered species through understanding the importance of ecosystem services that plants provide to people and addressing societal and global challenges.

BackgroundWe present the case report of synchronous trans‐fascial repair of a large congenital Morgagni hernia (MH) and low anterior resection using a fully robotic approach.MethodsA 61‐year old female presented with fresh red blood in her stool. She had a previous history of abdominal hysterectomy and a performance status of 0. Imaging revealed a low rectal cancer and incidental large MH.ResultsUsing the Da Vinci X platform the procedure was successfully performed; total operating time of 450 min, <200 ml blood loss and 5 days hospital stay. Post‐operative scan at 6 months, 1 and 2 years showed no evidence of hernia or cancer recurrence.ConclusionWe have demonstrated that complex multi‐visceral procedures can be safely performed on fully robotic platforms, even in previously disturbed surgical fields. The robotic approach may provide the opportunity for seamless multi‐speciality operating simultaneously in multiple body cavities.

BackgroundWe describe the technical operative details of the robotic repair of a type II endoleak (T2E) following endovascular abdominal aortic aneurysm repair (EVAR). We demonstrate that indocyanine green (ICG) can be used intra‐operatively to demonstrate perfusion of the colon following ligation of the inferior mesenteric artery (IMA) vessel feeding the aneurysm sac.MethodsA 74‐year old male underwent EVAR for a 5.8 cm infra‐renal abdominal aortic aneurysm using an E‐Tegra, Jotec Device (JOTEC Gmb, Lotzenäcker 23,D‐72379 Hechingen). Surveillance contrast CT (CTA) over the ensuing 30 months confirmed progressive sac expansion.ResultsICG confirmed colonic perfusion via the marginals after IMA ligation. Total operative time 56 min < 50 mls blood loss and 1‐day hospital stay. 3‐month follow‐up: CTA and ultrasound demonstrated complete resolution of T2E and adequately perfused colon.ConclusionA total robotic approach can be performed safely with intra‐operative ICG used to demonstrate colonic perfusion as an added safety measure.

Clinical outcomes in rheumatoid arthritis have greatly improved with therapeutic advances. Despite the availability of substantial clinical trial evidence, there is a lack of real-life data. The aim of this study was to assess disease status and quality of life in an outpatient population treated with biological disease-modifying anti-rheumatic drugs. Cross-sectional study recalling all patients ever treated in our unit with biological disease-modifying antirheumatic drugs. Clinical and demographic data, compliance, disease activity, functional status, joint deformities, and comorbidities were documented, and patients queried on occupational status, education, marital status and generic health related quality of life questionnaires. Recall was attended by 77 of the original 94 patients. At recall, median age was 63 years old, 82% of the patients were female and the median disease duration was 12 years. Biological therapy was started at a median of four years following disease onset. According to the disease activity score (DAS28), the percentage of patients with high, moderate, low disease activity or remission changed from 50, 45, 0 and 5 (pre-therapy) to 11, 37, 25 and 26 at recall, respectively; functional status was significantly improved. Seventy-five per cent of the patients retained the original treatment with good compliance. Lower Short Form-36 domain scores accompanied a low EQ-5D-3L score. Deceased patients (n = 6) had a lower estimated 10-year survival rate. In this group, biological therapy was discontinued at a higher frequency during follow-up. A high disease activity and a high HAQ disability index characterized most patients at pre-bDMARD onset. Despite therapy switches and regular follow-up, a significant percentage of patients still presented with moderate disease activity, functional impairment and a poor health-related quality of life.

BackgroundWorldwide, many patients with cancer, are infrequently referred to palliative care or are referred late. Oncologists and haematologists may act as gatekeepers, and their views may facilitate or hinder referrals to palliative care. This review aimed to identify, explore and synthesise their views on referrals systematically.MethodsDatabases of MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science and Cochrane were searched for articles from 01/01/1990 to 31/12/2019. All studies were scored for their methodological rigour using Hawker’s tool. Findings were synthesised using Popay’s narrative synthesis method and interpreted using a critical realist lens and social exchange theory.ResultsOut of 9336 initial database citations, 23 studies were included for synthesis. Five themes were developed during synthesis.1. Presuppositions of oncologists and haematologists about palliative care referral: Role conflict, abandonment, rupture of therapeutic alliance and loss of hope were some of the presuppositions that hindered palliative care referral. Negative emotions and perception of self-efficacy to manage palliative care need also hindered referral.2. Power relationships and trust issues: Oncologists and haematologists preferred to gatekeep the referral process and wished to control and coordinate the care process. They had diminished trust in the competency of palliative care providers.3. Making a palliative care referral: A daunting task: The stigma associated with palliative care, navigating illness and treatment associated factors, addressing patient and family attitudes, and overcoming organisational challenges made referral a daunting task. Lack of referral criteria and limited palliative care resources made the referral process challenging.4. Cost-benefit of palliative care referral: Pain and symptom management and psychosocial support were the perceived benefits, whereas inconsistencies in communication and curtailment of care were some of the costs associated with palliative care referral.5. Strategies to facilitate palliative care referral: Developing an integrated model of care, renaming and augmenting palliative care resources were some of the strategies that could facilitate a referral.ConclusionPresuppositions, power relationships, trust issues and the challenges associated with the task of referrals hindered palliative care referral. Oncologists and haematologists appraised the cost-benefit of making a palliative care referral. They felt that an integrated model of care, changing the name of palliative care and augmenting palliative care resources might facilitate a referral.

Gastrointestinal (GI) infections exert a significant public health burden in the United Kingdom and the numbers of episodes are increasing. Younger children are considered particularly vulnerable to infection, and can experience 2-3 GI infections episodes per year, with consequences being more severe for more disadvantaged children, who are much more likely to be admitted to hospital. Few qualitative studies have explored the lived experience of GI infection in the community in the UK. The aim of the study reported here was to contribute to addressing this evidence gap, by examining the consequences of GI infection for 'normal' family life. Eighteen mothers with young children who had recently experienced a gastrointestinal infection were recruited from two socioeconomically contrasting neighbourhoods in North West of England. The findings demonstrated that GI infections were particularly disruptive: experienced as disgusting, laborious and stressful and significantly impacted normal family routines. Women felt burdened by the heavy physical and emotional demands of caring for a GI infection, resulting in feelings of isolation and insufficient support in their caring role from male partners. Tensions also arose from interactions with external community organisations, particularly in complying with their regulations on infection which often undermined caregivers knowledge and expertise of what was best for their children. This study challenges assumptions that managing GI infections in the home is unproblematic and experienced by caregivers as a 'minor ailment.' Infection control measures need to incorporate insights gleaned from the day-to-day realities of caring for sick children in the community.

We recently wrote a letter reporting a potential outbreak of prolific vomiting in dogs with prolonged lethargy and inappetence, sometimes with diarrhoea ( VR , 15 February 2020, vol 186, p 191). Data collected by practices participating in the Small Animal Veterinary Surveillance Network (SAVSNET) also showed a profound rise in dogs presenting for non-specific gastroenteric disease, probably starting around November 2019 (see Fig 1 of the original letter). Statistical analysis has now confirmed this to be significantly outwith normal seasonal enteric disease fluctuation, therefore constituting an outbreak. Analysis of data submitted by laboratories to SAVSNET did not identify any equivalent increase in known enteric pathogen diagnoses. However, we did observe a regular winter peak in the …