Implementation of treatment escalation plans in an old age psychiatry inpatient hospital

A treatment escalation plan (TEP) enables timely and appropriate decision making in the management of deteriorating patients. The COVID-19 pandemic precipitated the widespread use of TEPs in acute care settings throughout the National Health Service (NHS) to facilitate safe and effective decision making. TEP proformas have not been developed for the inpatient psychiatric setting. This is particularly concerning in old age psychiatry inpatient wards where patients often have multiple compounding comorbidities and complex decisions regarding capacity are often made. Our aim for this quality improvement project was to pilot a novel TEP proforma within a UK old age psychiatry inpatient hospital. We first adapted a TEP proforma used in our partner acute tertiary hospital and implemented it on our old age psychiatry wards. We then further refined the form and gathered data about uptake, length of time to complete a TEP and the ceiling of care documented in the TEP. We also explored staff, patient and family views on the usefulness of TEP proformas using questionaries. TEP decisions were documented in 54% of patient records at baseline. Following revision and implementation of a TEP proforma this increased to 100% on our two wards. The mean time taken to complete a TEP was reduced from 7.1 days to 3.2 days following inclusion of the TEP proforma in admission packs. Feedback from staff showed improvements in understanding about TEP and improved knowledge of where these decisions were documented. We advocate the use of TEP proformas on all old age psychiatry inpatient wards to offer clear guidance to relatives and treating clinicians about the ceilings of care for patients. There are potentially wider benefits to healthcare systems by reducing inappropriate transfers between psychiatry and acute NHS hospitals.

Combined Structural and Functional Imaging of the Kidney Reveals Major Axial Differences in Proximal Tubule Endocytosis

BackgroundThe kidney proximal convoluted tubule (PCT) reabsorbs filtered macromolecules via receptor-mediated endocytosis (RME) or nonspecific fluid phase endocytosis (FPE); endocytosis is also an entry route for disease-causing toxins. PCT cells express the protein ligand receptor megalin and have a highly developed endolysosomal system (ELS). Two PCT segments (S1 and S2) display subtle differences in cellular ultrastructure; whether these translate into differences in endocytotic function has been unknown.MethodsTo investigate potential differences in endocytic function in S1 and S2, we quantified ELS protein expression in mouse kidney PCTs using real-time quantitative polymerase chain reaction and immunostaining. We also used multiphoton microscopy to visualize uptake of fluorescently labeled ligands in both living animals and tissue cleared using a modified CLARITY approach.ResultsUptake of proteins by RME occurs almost exclusively in S1. In contrast, dextran uptake by FPE takes place in both S1 and S2, suggesting that RME and FPE are discrete processes. Expression of key ELS proteins, but not megalin, showed a bimodal distribution; levels were far higher in S1, where intracellular distribution was also more polarized. Tissue clearing permitted imaging of ligand uptake at single-organelle resolution in large sections of kidney cortex. Analysis of segmented tubules confirmed that, compared with protein uptake, dextran uptake occurred over a much greater length of the PCT, although individual PCTs show marked heterogeneity in solute uptake length and three-dimensional morphology.ConclusionsStriking axial differences in ligand uptake and ELS function exist along the PCT, independent of megalin expression. These differences have important implications for understanding topographic patterns of kidney diseases and the origins of proteinuria.

Nutrient uptake during low-level fertilization of a large, seventh-order oligotrophic river

Uptake of nitrogen (total nitrogen (TN), NH4-N, and NO3-N) and phosphorus (total dissolved phosphorus (TDP) and total phosphorus (TP)) was quantified June through September 2009–2011 using whole-river fertilization in a seventh-order, P-limited river (Kootenai River, Idaho, USA), at discharges up to three orders of magnitude greater than previously studied. Mean uptake length (Sw) and uptake velocity (Vf) values were similar for dosed TDP and NH4; both had steep gradients indicating rapid uptake, while NO3-N did not. TP remained higher than reference levels. TN showed no clear pattern. Autotrophs accounted for 28% of daylight mean NO3-N uptake compared with 72% by heterotrophs. Nutrient uptake was strongly associated with chlorophyll accrual and epilithon growth rates. Mean midsummer epilithon growth and N rates roughly tripled late summer rates. TDP uptake length (Sw = 5.7 km) showed a slow increase with increasing stream order consistent with published findings. Mean TDP uptake velocity (Vf = 32 mm·min−1) was eight times greater than previously seen in smaller streams. Vf (10.9 ± 5 mm·min−1) and Sw (16.8. ± 7 km) for NO3-N increased with increasing river order and discharge.

Solute-specific scaling of inorganic nitrogen and phosphorus uptake in streams

Stream ecosystem processes such as nutrient cycling may vary with stream position in the network. Using a scaling approach, we examined the relationship between stream size and nutrient uptake length, which represents the mean distance that a dissolved solute travels prior to removal from the water column. Ammonium (NH4+) uptake length increased proportionally with stream size measured as specific discharge (discharge/stream width) with a scaling exponent = 1.01. In contrast, uptake lengths for nitrate (NO3−) and soluble reactive phosphorus (SRP) increased more rapidly than increases in specific discharge (scaling exponents = 1.19 for NO3− and 1.35 for SRP). Additionally, the ratio of inorganic nitrogen (N) uptake length to SRP uptake length declined with stream size; there was relatively lower demand for SRP compared to N as stream size increased. Finally, we related the scaling of uptake length with specific discharge to that of stream length using Hack's law and downstream hydraulic geometry. Ammonium uptake length increased less than proportionally with distance from the headwaters, suggesting a strong role for larger streams and rivers in regulating nutrient transport.

Solute specific scaling of inorganic nitrogen and phosphorus uptake in streams

Stream ecosystem processes such as nutrient cycling may vary with stream position in the watershed. Using a scaling approach, we examined the relationship between stream size and nutrient uptake length, which represents the mean distance that a dissolved solute travels prior to removal from the water column. Ammonium uptake length increased proportionally with stream size measured as specific discharge (discharge/stream width) with a scaling exponent = 1.01. In contrast, the scaling exponent for nitrate (NO3−) was 1.19 and for soluble reactive phosphorus (SRP) was 1.35, suggesting that uptake lengths for these nutrients increased more rapidly than increases in specific discharge. Additionally, the ratio of nitrogen (N) uptake length to SRP uptake length declined with stream size; there was lower demand for SRP relative to N as stream size increased. Ammonium and NO3− uptake velocity positively related with stream metabolism, while SRP did not. Finally, we related the scaling of uptake length and specific discharge to that of stream length using Hack's law and downstream hydraulic geometry. Ammonium uptake length increased less than proportionally with distance from the headwaters, suggesting a strong role for larger streams and rivers in regulating nutrient transport.

Nitrate retention and removal in Mediterranean streams bordered by contrasting land uses: a ¹⁵N tracer study

We used 15N-labelled nitrate (NO3−) additions to investigate pathways of nitrogen (N) cycling at the whole-reach scale in three stream reaches with adjacent forested, urban and agricultural land areas. Our aim was to explore among-stream differences in: (i) the magnitude and relative importance of NO3− retention (i.e. assimilatory uptake) and removal (i.e. denitrification), (ii) the relative contribution of the different primary uptake compartments to NO3− retention, and (iii) the regeneration, transformation and export pathways of the retained N. Streams varied strongly in NO3− concentration, which was highest in the agricultural stream and lowest in the forested stream. The agricultural stream also showed the lowest dissolved oxygen (DO) concentration and discharge. Standing stocks of primary uptake compartments were similar among streams and dominated by detritus compartments (i.e. fine and coarse benthic organic matter). Metabolism was net heterotrophic in all streams, although the degree of heterotrophy was highest in the agricultural stream. The NO3− uptake length was shortest in the agricultural stream, intermediate in the urban stream, and longest in the forested stream. Conversely, the NO3− mass-transfer velocity and the areal NO3− uptake rate were highest in the urban stream. Denitrification was not detectable in the forested stream, but accounted for 9% and 68% of total NO3− uptake in the urban and the agricultural stream, respectively. The relative contribution of detritus compartments to NO3− assimilatory uptake was greatest in the forested and lowest in the agricultural stream. In all streams, the retained N was rapidly regenerated back to the water column. Due to a strong coupling between regeneration and nitrification, most retained N was exported from the experimental reaches in the form of NO3−. This study provides evidence of fast in-stream N cycling, although the relative importance of N retention and removal varied considerably among streams. Results suggest that permanent NO3− removal via denitrification may be enhanced over temporary NO3− retention via assimilatory uptake in heterotrophic human-altered streams characterized by high NO3− and low DO concentrations.

Nitrate retention and removal in Mediterranean streams with contrasting land uses: a ¹⁵N tracer study

We used 15N-labelled nitrate (NO−3) additions to investigate nitrogen (N) cycling at the whole-reach scale in three Mediterranean streams subjected to contrasting land uses (i.e. forested, urban and agricultural). Our aim was to examine: i) the magnitude and relative importance of NO−3 retention (i.e. assimilatory uptake), and removal, (i.e. denitrification), ii) the relative contribution of the different primary uptake compartments to NO−3 retention, and iii) the regeneration, transformation and export pathways of the retained N. The concentration of NO−3 increased and that of dissolved oxygen (DO) decreased from the forested to the agricultural stream, with intermediate values in the urban stream. Standing stocks of primary uptake compartments were similar among streams and dominated by detritus compartments (i.e. fine and coarse benthic organic matter). In agreement, metabolism was net heterotrophic in all streams, although the degree of heterotrophy increased from the forested to the agricultural stream. The NO−3 uptake length decreased along this gradient, whereas the NO−3 mass-transfer velocity and the areal NO−3 uptake rate were highest in the urban stream. Denitrification was not detectable in the forested stream, but accounted for 9% and 68% of total NO−3 uptake in the urban and the agricultural stream, respectively. The relative contribution of detritus compartments to NO−3 assimilatory uptake was highest in the forested and lowest in the agricultural stream. In all streams, the retained N was rapidly transferred to higher trophic levels and regenerated back to the water column. Due to a strong coupling between regeneration and nitrification, most retained N was exported from the experimental reaches in the form of NO−3. This study evidences fast N cycling in Mediterranean streams. Moreover, results indicate that permanent NO−3 removal via denitrification may be enhanced over temporary NO−3 retention via assimilatory uptake in heterotrophic human-altered streams characterized by high NO−3 and low DO concentrations.