BackgroundClinicians are inaccurate at predicting survival. The ‘Surprise Question’ (SQ) is a screening tool that aims to identify people nearing the end of life. Potentially, its routine use could help identify patients who might benefit from palliative care services. The objective was to assess the accuracy of the SQ by time scale, clinician, and speciality.MethodsSearches were completed on Medline, Embase, CINAHL, AMED, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Open Grey literature (all from inception to November 2016). Studies were included if they reported the SQ and were written in English. Quality was assessed using the Newcastle–Ottawa Scale.ResultsA total of 26 papers were included in the review, of which 22 reported a complete data set. There were 25,718 predictions of survival made in response to the SQ. The c-statistic of the SQ ranged from 0.512 to 0.822. In the meta-analysis, the pooled accuracy level was 74.8% (95% CI 68.6–80.5). There was a negligible difference in timescale of the SQ. Doctors appeared to be more accurate than nurses at recognising people in the last year of life (c-statistic = 0.735 vs. 0.688), and the SQ seemed more accurate in an oncology setting 76.1% (95% CI 69.7–86.3).ConclusionsThere was a wide degree of accuracy, from poor to reasonable, reported across studies using the SQ. Further work investigating how the SQ could be used alongside other prognostic tools to increase the identification of people who would benefit from palliative care is warranted.Trial registrationPROSPERO CRD42016046564.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-017-0907-4) contains supplementary material, which is available to authorized users.

We found that BPSD are very common in older people admitted to an acute hospital. Patients and staff would benefit from more specialist psychiatric support.

BackgroundPrognostic accuracy in palliative care is valued by patients, carers, and healthcare professionals. Previous reviews suggest clinicians are inaccurate at survival estimates, but have only reported the accuracy of estimates on patients with a cancer diagnosis.ObjectivesTo examine the accuracy of clinicians’ estimates of survival and to determine if any clinical profession is better at doing so than another.Data SourcesMEDLINE, Embase, CINAHL, and the Cochrane Database of Systematic Reviews and Trials. All databases were searched from the start of the database up to June 2015. Reference lists of eligible articles were also checked.Eligibility CriteriaInclusion criteria: patients over 18, palliative population and setting, quantifiable estimate based on real patients, full publication written in English. Exclusion criteria: if the estimate was following an intervention, such as surgery, or the patient was artificially ventilated or in intensive care.Study Appraisal and Synthesis MethodsA quality assessment was completed with the QUIPS tool. Data on the reported accuracy of estimates and information about the clinicians were extracted. Studies were grouped by type of estimate: categorical (the clinician had a predetermined list of outcomes to choose from), continuous (open-ended estimate), or probabilistic (likelihood of surviving a particular time frame).Results4,642 records were identified; 42 studies fully met the review criteria. Wide variation was shown with categorical estimates (range 23% to 78%) and continuous estimates ranged between an underestimate of 86 days to an overestimate of 93 days. The four papers which used probabilistic estimates tended to show greater accuracy (c-statistics of 0.74–0.78). Information available about the clinicians providing the estimates was limited. Overall, there was no clear “expert” subgroup of clinicians identified.LimitationsHigh heterogeneity limited the analyses possible and prevented an overall accuracy being reported. Data were extracted using a standardised tool, by one reviewer, which could have introduced bias. Devising search terms for prognostic studies is challenging. Every attempt was made to devise search terms that were sufficiently sensitive to detect all prognostic studies; however, it remains possible that some studies were not identified.ConclusionStudies of prognostic accuracy in palliative care are heterogeneous, but the evidence suggests that clinicians’ predictions are frequently inaccurate. No sub-group of clinicians was consistently shown to be more accurate than any other.Implications of Key FindingsFurther research is needed to understand how clinical predictions are formulated and how their accuracy can be improved.

Pain was common but difficult to detect in hospitals in patients with dementia who had difficulties with self-report. It was associated with aggression and anxiety.

This paper provides new information on the evolution of the Himalayan foreland basin in the underreported region of the Kangra and Subathu sub-basins, NW India. Comparisons are made with the better documented co -eval sediments of Nepal and Pakistan to build up a broader picture of basin development. In the Subathu sub-basin, shallow marine sediments of the Palaeocene^lower Lutetian Subathu Formation are unconformably overlain by the continental alluvial Dagshai and Kasauli Formations and Siwalik Group.The start of continental deposition is now dated at younger than 31 Ma from detrital zircon ¢ssion track data, thereby de¢ning the duration of this major unconformity, which runs basin-wide along strike. Final exhumation of these basin sediments, as thrusting propagated into the basin, occurred by 5 Ma constrained from detrital apatite ¢ssion track data. In the Kangra sub-basin, the Subathu Formation is not exposed and the pre-Siwalik sediments consist of the Dharamsala Group, interpreted as the deposits of transverse-draining rivers. In this area, there is no evidence of westerly axial drainage as documented for coeval facies in Nepal. Similar to data reported along strike, facies analysis indicates that the sediments in NW India represent the ¢lled/over¢lled stages of the classic foreland basin evolutionary model, and the under¢lled stage is not represented anywhere along the length of the basin studied to date.

BackgroundThe acute hospital is a challenging place for a person with dementia. Behavioural and psychological symptoms of dementia (BPSD) are common and may be exacerbated by the hospital environment. Concerns have been raised about how BPSD are managed in this setting and about over reliance on neuroleptic medication. This study aimed to investigate how BPSD are managed in UK acute hospitals.Method(s)A longitudinal cohort of 230 patients with dementia admitted to two acute NHS hospitals. BPSD were measured every four days (Behave‐AD scale), as well as documentation of pharmacological prescriptions and non‐pharmacological management.ResultsThe overall prevalence of BPSD was 75%, with aggression and activity disturbance being the most common. Antipsychotics were prescribed for 28 (12%) patients; 70% of these prescriptions were new on admission. Benzodiazepines were prescribed for 27 (12%) patients, antidepressants were prescribed for 37 (16%) patients, and sedatives were prescribed for 14 (3%) patients. Patients who were prescribed antipsychotics, after adjusting for end of life medication, age and dementia severity, were significantly more likely to die (adjusted hazard ratio 5.78, 95% CI 1.57, 21.26, p = 0.008). Non‐pharmacological management was used in 55% of participants, most commonly psychosocial interventions (36%) with little evidence of monitoring their effectiveness. A form of restraint was used during 50 (22%) patients' admissions.ConclusionsAntipsychotic medications and psychosocial interventions were the main methods used to manage BPSD; however, these were not implemented or monitored in a systematic fashion.

BackgroundPain and delirium are common in people with dementia admitted to hospitals. These are often under-diagnosed and under-treated. Pain is implicated as a cause of delirium but this association has not been investigated in this setting.ObjectiveTo investigate the relationship between pain and delirium in people with dementia, on admission and throughout a hospital admission.DesignExploratory secondary analysis of observational prospective longitudinal cohort data.SettingTwo acute hospitals in the UK.MethodologyTwo-hundred and thirty participants aged ≥70 years were assessed for dementia severity, delirium ((Confusion Assessment Method (CAM), pain (Pain Assessment in Advanced Dementia (PAINAD)) scale and prescription of analgesics. Logistic and linear regressions explored the relationship between pain and delirium using cross-sectional data.ResultsPain at rest developed in 49%, and pain during activity for 26% of participants during their inpatient stay. Incident delirium developed in 15%, of participants, and 42% remained delirious for at least two assessments. Of the 35% of participants who were delirious and unable to self-report pain, 33% of these participants experienced pain at rest, and 56 experienced pain during activity. The odds of being delirious were 3.26 times higher in participants experiencing pain at rest (95% Confidence Interval 1.03–10.25, P = 0.044).ConclusionAn association between pain at rest and delirium was found, suggesting pain may be a risk factor for delirium. Since pain and delirium were found to persist and develop during an inpatient stay, regular pain and delirium assessments are required to manage pain and delirium effectively.

Overactive bladder (OAB) is a condition affecting millions of individuals in the United States. Anticholinergics are the mainstay of treatment. Bladder botulinum toxin injections have shown an improvement in symptoms of OAB equivalent to anticholinergic therapy. Percutaneous tibial nerve stimulation can decrease symptoms of urinary frequency and urge incontinence. Sacral neuromodulation for refractory patients has been approved by the Food and Drug Administration for treatment of OAB, urge incontinence, and urinary retention. Few randomized, head-to-head comparisons of the different available alternatives exist; however, patients now have increasing options to manage their symptoms and improve their quality of life.