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Combating sarcopenia in geriatric rehabilitation patients: study protocol of the EMPOWER-GR observational cohort, sarcopenia awareness survey and randomised controlled feasibility trial

Por: Verstraeten · L. M. · van Wijngaarden · J. P. · Tol-Schilder · M. · Meskers · C. G. · Maier · A. B.
Introduction

Sarcopenia is highly prevalent in geriatric rehabilitation patients. Resistance exercise training (RET) combined with protein supplementation is recommended to increase muscle mass and strength in older adults. However, sarcopenia awareness, feasibility to diagnose and treat sarcopenia, and efficacy of treatment in geriatric rehabilitation patients remain to be established.

Methods and analysis

Enhancing Muscle POWER in Geriatric Rehabilitation (EMPOWER-GR) encompasses four pillars: (1) an observational cohort study of 200 geriatric rehabilitation inpatients determining sarcopenia prevalence, functional and nutritional status at admission; (2) a survey among these 200 patients and 500 healthcare professionals and semistructured interviews in 30 patients and 15 carers determining sarcopenia awareness and barriers/enablers regarding diagnostics and treatment; (3) a feasibility, single-centre, randomised, controlled, open-label, two parallel-group trial in 80 geriatric rehabilitation patients with sarcopenia. The active group (n=40) receives three RET sessions per week and a leucine and vitamin D-enriched whey protein-based oral nutritional supplement two times per day in combination with usual care for 13 weeks. The control group (n=40) receives usual care. Primary outcomes are feasibility (adherence to the intervention, dropout rate, overall feasibility) and change from baseline in absolute muscle mass at discharge and week 13. Secondary outcomes are feasibility (participation rate) and change from baseline at discharge and week 13 in relative muscle mass, muscle strength, physical and functional performance, mobility, nutritional status, dietary intake, quality of life and length of stay; institutionalisation and hospitalisation at 6 months and mortality at 6 months and 2 years; (4) knowledge sharing on sarcopenia diagnosis and treatment.

Ethics and dissemination

Ethical exemption was received for the observational cohort study, ethics approval was received for the randomised controlled trial. Results will be disseminated through publications in scientific peer-reviewed journals, conferences and social media.

Trial registration number

NL9444.

Listen Carefully protocol: an exploratory case-control study of the association between listening effort and cognitive function

Por: Feldman · A. · Patou · F. · Baumann · M. · Stockmarr · A. · Waldemar · G. · Maier · A. M. · Vogel · A.
Introduction

A growing body of evidence suggests that hearing loss is a significant and potentially modifiable risk factor for cognitive impairment. Although the mechanisms underlying the associations between cognitive decline and hearing loss are unclear, listening effort has been posited as one of the mechanisms involved with cognitive decline in older age. To date, there has been a lack of research investigating this association, particularly among adults with mild cognitive impairment (MCI).

Methods and analysis

15–25 cognitively healthy participants and 15–25 patients with MCI (age 40–85 years) will be recruited to participate in an exploratory study investigating the association between cognitive functioning and listening effort. Both behavioural and objective measures of listening effort will be investigated. The sentence-final word identification and recall (SWIR) test will be administered with single talker non-intelligible speech background noise while monitoring pupil dilation. Evaluation of cognitive function will be carried out in a clinical setting using a battery of neuropsychological tests. This study is considered exploratory and proof of concept, with information taken to help decide the validity of larger-scale trials.

Ethics and dissemination

Written approval exemption was obtained by the Scientific Ethics Committee in the central region of Denmark (De Videnskabsetiske Komiteer i Region Hovedstaden), reference 19042404, and the project is registered pre-results at clinicaltrials.gov, reference NCT04593290, Protocol ID 19042404. Study results will be disseminated in peer-reviewed journals and conferences.

Fall prevention in hospitals and nursing homes: Clinical practice guideline

Abstract

Background

Falls and their consequences are particularly common in older adults in hospitals and long-term care (LTC) facilities.

Aim

To avoid falls and their consequences, and provide nurses with an overview of all relevant research literature on fall prevention, and a practice guideline on fall prevention in older adults was developed.

Methods

The development process included a systematic literature review to identify systematic reviews and primary studies on the topic of fall prevention, an assessment of the study quality, the preparation of meta-analyses to summarize the results, and the application of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to grade the scientific literature. The guideline panel and an external multidisciplinary team graded the recommendations using the Delphi method. In addition, the panel and team formulated expert opinions.

Results

A total of 79 randomized controlled trials on fall prevention were identified, which formed the basis of the recommendations. Strongly recommended measures for both settings included multifactorial interventions, professionally supported body exercise interventions, and education and counselling interventions. The panel and team did not recommend the use of a specific assessment tool for fall risk assessment, low-floor beds in hospitals, or body exercise interventions in frail residents.

Linking Evidence to Action

During the development of this guideline, particular attention was paid to collecting evidence-based knowledge relevant to practice. By applying the recommendations, the outlined nursing care is justified, enabling healthcare personnel to achieve the overriding goal of providing optimal care to persons at risk of falling. Evidence for several fall prevention interventions was graded as very low. Sound intervention studies are necessary to strengthen the confidence in the evidence for low-floor beds, alarm sensor systems, medication review, and staff education in hospitals.

Characteristics and management of adolescents attending the ED with fever: a prospective multicentre study

Por: Borensztajn · D. · Hagedoorn · N. N. · Carrol · E. · von Both · U. · Dewez · J. E. · Emonts · M. · van der Flier · M. · de Groot · R. · Herberg · J. · Kohlmaier · B. · Levin · M. · Lim · E. · Maconochie · I. · Martinon Torres · F. · Nijman · R. · Pokorn · M. · Rivero-Calle · I. · Tsolia
Objective

Most studies on febrile children have focused on infants and young children with serious bacterial infection (SBI). Although population studies have described an increased risk of sepsis in adolescents, little is known about febrile adolescents attending the emergency department (ED). We aimed to describe patient characteristics and management of febrile adolescents attending the ED.

Design and setting

The MOFICHE/PERFORM study (Management and Outcome of Febrile Children in Europe/Personalised Risk assessment in Febrile illness to Optimise Real-life Management across the European Union), a prospective multicentre study, took place at 12 European EDs. Descriptive and multivariable regression analyses were performed, comparing febrile adolescents (12–18 years) with younger children in terms of patient characteristics, markers of disease severity (vital signs, clinical alarming signs), management (diagnostic tests, therapy, admission) and diagnosis (focus, viral/bacterial infection).

Results

37 420 encounters were included, of which 2577 (6.9%) were adolescents. Adolescents were more often triaged as highly urgent (38.9% vs 34.5%) and described as ill appearing (23.1% vs 15.6%) than younger children. Increased work of breathing and a non-blanching rash were present less often in adolescents, while neurological signs were present more often (1% vs 0%). C reactive protein tests were performed more frequently in adolescents and were more often abnormal (adjusted OR (aOR) 1.7, 95% CI 1.5 to 1.9). Adolescents were more often diagnosed with SBI (OR 1.8, 95% CI 1.6 to 2.0) and sepsis/meningitis (OR 2.3, 95% CI 1.1 to 5.0) and were more frequently admitted (aOR 1.3, 95% CI 1.2 to 1.4) and treated with intravenous antibiotics (aOR 1.7, 95% CI 1.5 to 2.0).

Conclusions

Although younger children presented to the ED more frequently, adolescents were more often diagnosed with SBI and sepsis/meningitis. Our data emphasise the importance of awareness of severe infections in adolescents.

Cross-sectional study of nutritional intake among patients undergoing tuberculosis treatment along the Myanmar-Thailand border

Por: Damji · K. · Hashmi · A. H. · Kyi · L. L. · Vincenti-Delmas · M. · Htun · W. P. P. · Ko Ko Aung · H. · Brummaier · T. · Angkurawaranon · C. · Carrara · V. I. · Nosten · F.
Objective

This study summarises nutritional intake among patients with tuberculosis (TB) along the Myanmar–Thailand border according to the local diet.

Setting

TB clinic along the Myanmar–Thailand border.

Participants

Cross-sectional surveys of 24-hour food recall were conducted with participants receiving anti-TB treatment. Participants were purposively selected to reflect proportion of age, sex and HIV co-infection based on historical patient records. Out of a total of 28 participants, 20 (71.4%) were men and 5 (17.9%) were co-infected with HIV.

Primary and secondary outcome measures

The primary outcome compared actual recorded intake to recommended intake. Secondary outcomes compared weight gain and body mass index (BMI) from diagnosis to time of survey.

Results

There were no significant differences in macronutrient or micronutrient intake by sex or for patients supplementing their rations. Mean treatment length at time of survey was 20.7 weeks (95% CI: 16.5 to 24.8). A significantly higher proportion of women (8/8, 100%) met caloric requirements compared with men (9/20, 45.0%, p=0.010), but few participants met other macronutrient or micronutrient requirements, with no significant differences by sex or for patients supplementing their rations. From diagnosis to the time of the survey, participants averaged significant weight gain of 6.48 kg (95% CI: 3.87 to 9.10) and increased BMI of 2.47 kg/m2 (95% CI: 1.45 to 3.49; p=0.0001 for both). However, 50% (14/28) still had mild or more severe forms of malnutrition.

Conclusions

This cross-sectional survey of nutritional intake in patients undergoing TB treatment in a sanatorium setting demonstrates the difficulty in sufficiently meeting nutritional demands, even when providing nutritional support.

Defining CD4 T helper and T regulatory cell endotypes of progressive and remitting pulmonary sarcoidosis (BRITE): protocol for a US-based, multicentre, longitudinal observational bronchoscopy study

Por: Koth · L. L. · Harmacek · L. D. · White · E. K. · Arger · N. K. · Powers · L. · Werner · B. R. · Magallon · R. E. · Grewal · P. · Barkes · B. Q. · Li · L. · Gillespie · M. · Collins · S. E. · Cardenas · J. · Chen · E. S. · Maier · L. A. · Leach · S. M. · OConnor · B. P. · Hamzeh · N. Y.
Introduction

Sarcoidosis is a multiorgan granulomatous disorder thought to be triggered and influenced by gene–environment interactions. Sarcoidosis affects 45–300/100 000 individuals in the USA and has an increasing mortality rate. The greatest gap in knowledge about sarcoidosis pathobiology is a lack of understanding about the underlying immunological mechanisms driving progressive pulmonary disease. The objective of this study is to define the lung-specific and blood-specific longitudinal changes in the adaptive immune response and their relationship to progressive and non-progressive pulmonary outcomes in patients with recently diagnosed sarcoidosis.

Methods and analysis

The BRonchoscopy at Initial sarcoidosis diagnosis Targeting longitudinal Endpoints study is a US-based, NIH-sponsored longitudinal blood and bronchoscopy study. Enrolment will occur over four centres with a target sample size of 80 eligible participants within 18 months of tissue diagnosis. Participants will undergo six study visits over 18 months. In addition to serial measurement of lung function, symptom surveys and chest X-rays, participants will undergo collection of blood and two bronchoscopies with bronchoalveolar lavage separated by 6 months. Freshly processed samples will be stained and flow-sorted for isolation of CD4 +T helper (Th1, Th17.0 and Th17.1) and T regulatory cell immune populations, followed by next-generation RNA sequencing. We will construct bioinformatic tools using this gene expression to define sarcoidosis endotypes that associate with progressive and non-progressive pulmonary disease outcomes and validate the tools using an independent cohort.

Ethics and dissemination

The study protocol has been approved by the Institutional Review Boards at National Jewish Hospital (IRB# HS-3118), University of Iowa (IRB# 201801750), Johns Hopkins University (IRB# 00149513) and University of California, San Francisco (IRB# 17-23432). All participants will be required to provide written informed consent. Findings will be disseminated via journal publications, scientific conferences, patient advocacy group online content and social media platforms.

Distribution and specificity of high-sensitivity cardiac troponin T in older adults without acute cardiac conditions: cross-sectional results from the population-based AugUR study

Por: Dietl · A. · Zimmermann · M. E. · Brandl · C. · Wallner · S. · Burkhardt · R. · Maier · L. S. · Luchner · A. · Heid · I. M. · Stark · K. J.
Objective

European guidelines recommended a uniform upper reference limit of high-sensitivity cardiac troponin T (hsTnT) to rule out non-ST segment elevation myocardial infarction. Our study aimed to provide a hsTnT reference distribution and to assess the specificity of the 14 ng/L cut-off value in the mobile population ≥70 years of age.

Design

A cross-sectional analysis was performed in the German AugUR study (Altersbezogene Untersuchungen zur Gesundheit der University of Regensburg).

Setting

Study population was the mobile population aged 70+ years living in the city and county of Regensburg, Germany.

Participants

A random sample was derived from the local population registries of residence. Of the 5644 individuals invited, 1133 participated (response ratio=20.1%). All participants came to the study centre and were mentally and physically mobile to conduct the protocol (face-to-face interview, blood draw and standardised transthoracic echocardiography). None of the participants was in an acute state of myocardial infarction.

Results

Among the 1129 individuals with hsTnT measurements (overall median=10.0 ng/L

(25th, 75th percentile)=(7.0, 15.0 ng/L)), hsTnT was higher among the older individuals and higher among men (men 70–74 years median=9.6 ng/L (7.2, 13.1 ng/L); men 90–95 years median=21.2 ng/L (14.6, 26.0 ng/L); women 70–74 years median=6.3 ng/L (4.7, 8.7 ng/L); and women 90–95 years median=18.0 ng/L (11.0, 21.0 ng/L)). In participants with impaired kidney function (eGFRcrea2), hsTnT was elevated (median=13.6 ng/L (9.4, 20.6 ng/L)).

Specificity of recommended upper reference limit, 14 ng/L, is 68%. Most false positives were among men aged >79 years (specificity=34%). In a healthy subgroup (n=96, none of the following: overt heart disease, impaired renal function, blood pressure >160/100 mm Hg, left ventricular hypertrophy and diastolic/systolic dysfunction), specificity was 90%.

Conclusion

In the elderly population without acute myocardial infarction, hsTnT further increases with age showing different levels for men and women. The specificity of the 14 ng/L cut-off is considerably lower than 99%, even in healthy subjects.

Comparison of FORTA, PRISCUS and EU(7)-PIM lists on identifying potentially inappropriate medication and its impact on cognitive function in multimorbid elderly German people in primary care: a multicentre observational study

Por: Krüger · C. · Schäfer · I. · van den Bussche · H. · Bickel · H. · Dreischulte · T. · Fuchs · A. · König · H.-H. · Maier · W. · Mergenthal · K. · Riedel-Heller · S. G. · Schön · G. · Weyerer · S. · Wiese · B. · von Renteln-Kruse · W. · Langebrake · C. · Scherer · M.
Objectives

Our study aimed to assess the frequency of potentially inappropriate medication (PIM) use (according to three PIM lists) and to examine the association between PIM use and cognitive function among participants in the MultiCare cohort.

Design

MultiCare is conducted as a longitudinal, multicentre, observational cohort study.

Setting

The MultiCare study is located in eight different study centres in Germany.

Participants

3189 patients (59.3% female).

Primary and secondary outcome measures

The study had a cross-sectional design using baseline data from the German MultiCare study. Prescribed and over-the-counter drugs were classified using FORTA (Fit fOR The Aged), PRISCUS (Latin for ‘time-honoured’) and EU(7)-PIM lists. A mixed-effect multivariate linear regression was performed to calculate the association between PIM use patients’ cognitive function (measured with (LDST)).

Results

Patients (3189) used 2152 FORTA PIM (mean 0.9±1.03 per patient), 936 PRISCUS PIM (0.3±0.58) and 4311 EU(7)-PIM (1.4±1.29). The most common FORTA PIM was phenprocoumon (13.8%); the most prevalent PRISCUS PIM was amitriptyline (2.8%); the most common EU(7)-PIM was omeprazole (14.0%). The lists rate PIM differently, with an overall overlap of 6.6%. Increasing use of PIM is significantly associated with reduced cognitive function that was detected with a correlation coefficient of –0.60 for FORTA PIM (p=0.002), –0.72 for PRISCUS PIM (p=0.025) and –0.44 for EU(7)-PIM (p=0.005).

Conclusion

We identified PIM using FORTA, PRISCUS and EU(7)-PIM lists differently and found that PIM use is associated with cognitive impairment according to LDST, whereby the FORTA list best explained cognitive decline for the German population. These findings are consistent with a negative impact of PIM use on multimorbid elderly patient outcomes.

Trial registration number

ISRCTN89818205.

Impact of prehabilitation on objectively measured physical activity levels in elective surgery patients: a systematic review

Por: Wagnild · J. M. · Akowuah · E. · Maier · R. H. · Hancock · H. C. · Kasim · A.
Objective

To systematically review the impact of prehabilitation on objectively measured physical activity (PA) levels in elective surgery patients.

Data sources

Articles published in Web of Science Core Collections, PubMed, Embase (Ovid), CINAHL (EBSCOHost), PsycInfo (EBSCOHost) and CENTRAL through August 2020.

Study selection

Studies that met the following criteria: (1) written in English, (2) quantitatively described the effect(s) of a PA intervention among elective surgery patients prior to surgery and (3) used and reported objective measures of PA in the study.

Data extraction and synthesis

Participant characteristics, intervention details, PA measurement, and clinical and health-related outcomes were extracted. Risk of bias was assessed following the revised Cochrane risk of bias tool. Meta-analysis was not possible due to heterogeneity, therefore narrative synthesis was used.

Results

6533 unique articles were identified in the search; 21 articles (based on 15 trials) were included in the review. There was little evidence to suggest that prehabilitation is associated with increases in objectively measured PA, but this may be due to insufficient statistical power as most (n=8) trials included in the review were small feasibility/pilot studies. Where studies tested associations between objectively measured PA during the intervention period and health-related outcomes, significant beneficial associations were reported. Limitations in the evidence base precluded any assessment via meta-regression of the association between objectively measured PA and clinical or health-related outcomes.

Conclusions

Additional large-scale studies are needed, with clear and consistent reporting of objective measures including accelerometry variables and outcome variables, to improve our understanding of the impact of changes in PA prior to surgery on surgical and health-related outcomes.

PROSPERO registration number

CRD42019151475.

Giving midwives a voice – Qualitative perspectives of an ‘empowering decision‐making workshop’

Abstract

Aim/objective

To establish midwives’ perceptions of the value of workshops designed to empower their decision-making and leadership skills using validated midwifery clinical reasoning frameworks and appreciative inquiry methods.

Background

The medical lens of childbirth can disempower women and midwives. Midwives often face challenges navigating their role as autonomous practitioners and advocates for shared decision-making, particularly when there is tension between women's wishes, governance frameworks and organisational requirements. This can lead to ‘Midwifery Abdication’ and/or the midwifery voice being silenced.

Design/Methods

Appreciative inquiry, involving qualitative analysis of 31 midwives’ personal reflections during ‘Empowering Midwives’ Decision-Making’ workshops. Standards for reporting qualitative research (SRQR criteria) guided the preparation of this manuscript.

Results

Decision-making tools and ‘appreciative’ strategies can strengthen leadership attributes, enhance feelings of empowerment and deepen understanding. Reflecting on ‘Midwifery Abdication’ was perceived as confronting. Workshop activities offered understanding the reasons why ‘Midwifery Abdication’ may or may not occur. One overarching, key theme was identified: ‘Finding my midwifery voice’. This theme encompassed three sub-themes: ‘I am not alone’, ‘Using leadership to promote collaboration to effect change’ and ‘An onward journey of enlightenment and empowerment’.

Conclusion

Midwives need to find their voice and develop skills in both clinical reasoning and transformative reflection. Workshops, using Appreciative Inquiry approaches, that focused on reflection, clinical decision-making and ‘Midwifery Abdication’, facilitate this and may create feelings of reunification in midwives and rejuvenate inherent passion for the profession.

Relevance to clinical practice

Sharing feelings around providing care in the often-contested space that is advocating for women using midwifery philosophy may provide relief from moral distress and a sense of shared identity desperately sought after by midwives struggling to navigate the increasingly complex terrain of maternity care. Findings encourage the need for further discussions around strengthening midwifery leadership which may be achievable using Appreciative Inquiry frameworks and approaches.

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