Qualitative, grounded theory exploration of patients' experience of early mobilisation, rehabilitation and recovery after critical illness

RATIONALE

Physical rehabilitation (encompassing early mobilisation) of the critically ill patient is recognised best practice; however, further work is needed to explore the patients' experience of rehabilitation qualitatively; a better understanding may facilitate implementation of early rehabilitation and elucidate the journey of survivorship.

OBJECTIVES

To explore patient experience of physical rehabilitation from critical illness during and after a stay on intensive care unit (ICU).

DESIGN

Exploratory grounded theory study using semistructured interviews.

SETTING

Adult medical/surgical ICU of a London teaching hospital.

PARTICIPANTS

A purposive sample of ICU survivors with intensive care unit acquired weakness (ICUAW) and an ICU length of stay of >72 hours.

ANALYSIS

Data analysis followed a four-stage constant comparison technique: open coding, axial coding, selective coding and model development, with the aim of reaching thematic saturation. Peer debriefing and triangulation through a patient support group were carried out to ensure credibility.

MAIN RESULTS

Fifteen people were interviewed (with four relatives in attendance). The early rehabilitation period was characterised by episodic memory loss, hallucinations, weakness and fatigue, making early rehabilitation arduous and difficult to recall. Participants craved a paternalised approach to care in the early days of ICU.The central idea that emerged from this study was recalibration of the self. This is driven by a lost sense of self, with loss of autonomy and competence; dehumanised elements of care may contribute to this. Participants described a fractured life narrative due to episodic memory loss, meaning that patients were shocked on awakening from sedation by the discrepancy between their physical form and cognitive representation of themselves.

CONCLUSIONS

Recovery from ICUAW is a complex process that often begins with survivors exploring and adapting to a new body, followed by a period of recovering autonomy. Rehabilitation plays a key role in this recalibration period, helping survivors to reconstruct a desirable future.

Lessons learned from a pneumocystis pneumonia outbreak at a Scottish renal transplant centre

BACKGROUND

Pneumocystis pneumonia (PCP) is an opportunistic infection occurring in renal transplant patients. Over a 14-month period an increase in PCP cases was identified among our renal transplant cohort.

AIM

The outbreak population was studied to identify potential risk factors for the development of PCP.

METHODS

A retrospective analysis of hospital records was carried out, with each case being matched with two case-linked controls. Information was collected on patient demographics, laboratory tests, and hospital visits pre and post development of infection.

FINDINGS

No patients were receiving PCP prophylaxis at the time of infection and mean time from transplantation to developing PCP was 4.7 years (range: 0.51-14.5). The PCP group had a significantly lower mean estimated glomerular filtration rate than the control group (29.3 mL/min/1.73 m² vs 70 mL/min^-1 (P = 0.0007)). Three patients were treated for active cytomegalovirus (CMV) infection prior to PCP diagnosis and two had active CMV at the time of diagnosis compared to none in the control group (P = 0.001). Those who developed PCP were more likely to have shared a hospital visit with another patient who went on to develop PCP; 37% of clinic visits vs 19% (P = 0.014).

CONCLUSION

This study highlights the ongoing risk of opportunistic infection several years after transplantation and adds weight to potential person-to-person Pneumocystis jirovecii transmission. Risk factors have been identified which may highlight those most at risk, enabling targeted rather than blanket long-term PCP prophylaxis.

Predictors of malignant brain edema after mechanical thrombectomy for acute ischemic stroke

BACKGROUND

Malignant brain edema (MBE) is a devastating complication in ischemic stroke. Data on MBE in patients who have had mechanical thrombectomy (MT) are relatively scarce.

OBJECTIVE

To investigate the incidence, predictors, and clinical outcomes of MBE in patients after MT.

METHODS

We included 130 consecutive patients after MT caused by anterior circulation large vessel occlusion stroke, treated with MT. MBE was defined as a midline shift of ≥5 mm on the follow-up imaging within 72 hours after MT. Characteristics of patients at admission and details of treatment were collected. The 90-day modified Rankin scale score was used as a measure of functional outcomes.

RESULTS

Of the 130 patients (age, 68.6±10.9 years; male, 50%), 35 (26.9%) patients developed MBE. The patients with MBE had a lower rate of functional independence (OR=7.831; 95% CI 1.731 to 35.427; p=0.008) and significantly higher mortality at 90 days (OR=7.958; 95% CI 2.274 to 27.848; p=0.001) than patients without MBE. In 104 (80%) patients with successful recanalization (modified Thrombolysis in Cerebral Infarction score of 2b-3), 24 (23.1%) patients exhibited MBE. After adjustment for confounding, ICA occlusion (OR=3.746; 95% CI 1.169 to 12.006; p=0.026) and worse collateral score (grade 1 vs grade 0: OR=0.727; 95% CI 0.192 to 2.753; p=0.638; grade 2 vs grade 0: OR=0.130; 95% CI 0.021 to 0.819; p=0.030) were significantly associated with the development of MBE, despite successful recanalization.

CONCLUSIONS

MBE after MT is not uncommon and was related to poor functional outcomes. Localization of a vessel occlusion and collateral status may play a role in the development of MBE.

Measuring the impact of driving status: The Centre for Research on Safe Driving-Impact of Driving Status on Quality of Life (CRSD-IDSQoL) tool

BACKGROUND.

Driving an automobile is often considered an activity of daily living and is crucial to quality of life for many individuals. Following driving cessation, quality of life may become compromised.

PURPOSE.

The Centre for Research on Safe Driving-Impact of Driving Status on Quality of Life (CRSD-IDSQoL) was designed to measure various elements of quality of life and how those elements are affected by driving status.

METHOD.

The CRSD-IDSQoL was cross-sectionally administered to a convenience sample of 114 individuals (mean age 65.8 years). Exploratory factor analysis was used to examine the factor structure.

FINDINGS.

The results supported three factors. Following adjustments for conceptual fit, Cronbach's alphas for the Community Mobility, Emotional, and Resources and Safety domains were .82, .84, and .74, respectively. Community Mobility was positively associated with distance driven per week.

IMPLICATIONS.

The CRSD-IDSQoL may be a useful tool to study quality-of-life impacts of driving cessation. Further evaluation of the tool is warranted.

[Hospital-at-home Integrated Care Programme tailored to older patients with disabling acute processes: identification of prognostic factors]

INTRODUCTION

Several authors have demonstrated the efficacy of different hospital-at-home strategies in older patients. The identification of prognostic factors is key for improving the targeting process of candidates.

METHODS

We performed an analysis of a cohort of older patients attended due to disabling health crises (medical, orthopaedics, or stroke) by a hospital-at-home scheme developed in an integrated care institution over a 5-year period. Main outcomes were: health crisis resolution (discharge to Primary Care); functional resolution (relative functional gain ≥35%), and their combined variable. A logistic regression analysis was performed, including clinical variables from Comprehensive Geriatric Assessment at admission to detect factors related to favourable outcomes.

RESULTS

A total of 484 patients were included. The main characteristics were: age 84.4 (6.7), female gender 69%, baseline Barthel score 74.2 (22.6), family-private caregiver/nursing home 82%/18%, referral from hospital wards/emergency department-community in 55%/45%. The main results (for selected processes medical/orthopaedics/stroke) were: health crisis resolution 71.7/87.5/77.6%; functional resolution 72.1/84.9/73.5%; favourable crisis resolution (health crisis resolution with functional resolution) 67.1/81.6/67.3%. Favourable crisis resolution was associated with [OR (95%CI)]: orthopaedic as main diagnosis [2.00 (1.22-3.29)], Barthel score at admission higher than 40 points [2.00 (1.18-3.38)], and the absence of pressure ulcers at admission [2.80 (1.68-4.65)].

CONCLUSIONS

Patients presenting with an orthopaedic diagnosis, not having severe disability at admission, and not having pressure ulcers at admission could obtain better results on favourable crisis resolution. Suffering cognitive impairment or delirium, or being institutionalised, was not found related with less favourable results.

Cognitive functions and jugular venous reflux in severe mitral regurgitation: A pilot study

Cardiac diseases with elevated central venous pressure have higher frequency of jugular venous reflux (JVR), which is associated with decreased cerebral blood flow and white matter hyperintensities. Whether patients with severe mitral-regurgitation (SMR) have poorer cognitive functions and whether JVR is involved were determined in this pilot study. Patients with SMR and age/sex-matched controls were prospectively recruited. Neuropsychological tests such as global cognitive (Mini-Mental State Examination, MMSE), verbal memory, executive, and visuospatial domains were performed. Cardiac parameters by cardiac catheterisation and echocardiography, and the frequency of JVR by colour-coded duplex ultrasonography were obtained. Forty patients with SMR and 40 controls (71.1±12.2, 38-89 years; 75% men) were included. Compared with the controls, patients with SMR had lower scores in all neuropsychological tests but only MMSE and visuospatial test scores were statistically significant after adjusting for age, sex, and educational level. We further adjusted for cardiovascular risk factors; the significance remained in the visuospatial test but diminished in MMSE. Multivariate linear regression analyses adjusted for age, sex, and educational level showed that JVR combined with high right-atrial-pressure (RAP > 50th-percentile, 12 mmHg) was significantly associated with poorer performances in both MMSE [right JVR: B coefficient(95% confidence interval,p) = -2.83(-5.46-0.20, 0.036); left JVR: -2.77(-5.52-0.02, 0.048)] and visuospatial test [right JVR: -4.52(-8.89-0.16, 0.043); left JVR: -4.56(-8.81-0.30, 0.037)], with significances that remained after further adjusting for cardiovascular risk factors. Our pilot results suggest that retrogradely-transmitted venous pressure might be involved in the mechanisms mediating the relationship between cardiac diseases and brain functions.

Post-operative mortality rates for neck of femur fracture at Waitemata District Health Board

AIM

Mortality rates of up to 38% at one year have been reported following surgery for neck of femur fractures. The aim of this review is to evaluate the post-operative mortality rates and trends over time for patients with fractured neck of femur at Waitemata District Health Board.

METHOD

A retrospective cohort study of all patients who received surgery following a neck of femur fracture at Waitemata District Health Board between 2009 and 2016. Inpatient data was retrieved from electronic hospital records and mortality rates from the Ministry of Health, New Zealand. Analyses included crude mortality rates and trends over time, and time-to-theatre from presentation with neck of femur fracture.

RESULTS

A total of 2,822 patients were included in the study; mean age 81.9 years, 70.4% female and 29.6% male. Overall post-operative crude rates for inpatient, 30-day and one-year mortality were 3.7%, 7.2% and 23.8% respectively. Adjusted analyses showed a statistically significant decrease in mortality rates between 2009 and 2016 at inpatient (p=0.001), 30 days (p=<0.001) and one year (p=<0.001) time periods. There was also a significant association between time-to-theatre and mortality at inpatient (p=0.002), 30 days (p=0.0001), and one year (p=0.0002) time periods.

CONCLUSION

Mortality rates following surgery for fractured NOF have significantly improved over recent years at Waitemata District Health Board. Reduced time-to-theatre is associated with decreased inpatient, 30-day and one-year mortality.

Aussiedler Mortality (AMOR): cohort studies on ethnic German migrants from the Former Soviet Union

PURPOSE

The Aussiedler Mortality cohorts represent the unique migrant group of ethnic Germans (resettlers) from the former Soviet Union who migrated to Germany mainly after the fall of the iron curtain in 1989. Resettlers are the second largest migrant group in Germany and their health status was largely unknown before the cohorts were set up.

PARTICIPANTS

Four retrospective register-based cohorts were set up in different federal states of Germany, each focussing on different health aspects. In total, the cohorts include 92 362 resettlers (men: 51.5%, women: 48.5%) who immigrated between 1990 and 2005 with a mean age at immigration of 36.6 years (range 0-105 years). Resettlers are of German ancestry and they are immediately granted the German citizenship with all rights and duties.

FINDINGS TO DATE

Vital status and causes of death (International Classification of Diseases codes based on death certificates or record linkage) were collected for three cohorts as well as cancer incidence and incidence of acute myocardial infarction in three of the cohorts. Currently, an observation period of 20 years (1990-2009) is covered. Overall mortality among resettlers was surprisingly lower in comparison to the German population with standardised mortality ratios of 0.87 (95% confidence limits 0.84-0.91) for women and 0.96 (0.92-0.99) for men, and even stronger for cardiovascular diseases (women: 0.84 (0.79-0.89); men: 0.80 (0.75-0.86). However, observed differences can neither be explained by the 'healthy migrant effect' nor by common behavioural risk factors and may be related to factors which have not yet been studied.

FUTURE PLANS

The existing cohorts will be continued and prospective studies on resettlers are underway: one cohort will be followed-up prospectively and two other large prospective cohort studies in Germany will be used for a detailed assessment of lifestyle, environmental and genetic/epigenetic factors on the mortality and morbidity pattern of resettlers.

Association between circulating mononuclear cell mitochondrial DNA copy number and in-hospital mortality in septic patients: A prospective observational study based on the Sepsis-3 definition

Purpose

To explore the association between circulating mononuclear cell mitochondrial DNA copy number and the prognosis of sepsis patients based on the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3 definition).

Methods

A total of 200 adult patients who had recently devoloped sepsis were prospectively recruited as the study cohort. Demographic and clinical data were recorded along with a 28-day outcome. Mononuclear cell mtDNA copy number was assessed by quantitative PCR.

Results

The 28-day outcome of sepsis patients was significantly associated with circulating mononuclear cell mtDNA copy number. The median mononuclear cell relative mtDNA copy number of survivors was significantly higher than that of nonsurvivors (406.68, range 196.65–625.35 vs. 320.57, range 175.98–437.33, p = 0.001). The Cox proportional hazard survival model analysis indicated that mononuclear cell relative mtDNA copy number was significantly negative associated with the 28-day outcome. For every additional unit of mononuclear cell mtDNA relative copy number, the risk of death falls by 0.1% (HR = 0.999, 95% CI = 0.998 to 1.000, p = 0.017).

Conclusions

Our data indicate first that circulating mononuclear cellular mtDNA copy number might be helpful for outcome predictions in sepsis patients, and second that lower mtDNA copy number implied poor prognosis.

Estimation of Arterial Viscosity Based on an Oscillometric Method and Its Application in Evaluating the Vascular Endothelial Function

This paper proposes an algorithm for estimating the arterial viscosity using cuff pressures and pulse waves measured by an automatic oscillometric sphygmomanometer. A change in the arterial viscosity during the enclosed-zone flow-mediated dilation test is calculated as an index for evaluating the vascular endothelial function %η. In all, 43 individuals participated in this study. After the index %η was calculated, the accuracy of the index %η in distinguishing healthy subjects and subjects at a high risk of arteriosclerosis was tested via a receiving operating characteristic (ROC) analysis. The calculated %η for the healthy participants and those at a high risk of arteriosclerosis was 13.4 ± 55.1% and -32.7 ± 34.0% (mean ± S.D.), respectively. The area under the ROC curve was 0.77. Thus, it was concluded that the proposed method can be used to evaluate the vascular endothelial function.

Choriocapillaris flow impairment surrounding geographic atrophy correlates with disease progression

Purpose

To evaluate the correlation between the choriocapillaris (CC) flow alterations around geographic atrophy (GA) and the GA yearly growth rate (yGR) in patients with dry age-related macular degeneration (AMD).

Methods

We retrospectively reviewed and analyzed spectral domain optical coherence tomography (SD-OCT) and SD-OCT angiography images of consecutive patients with GA acquired using the Cirrus OCT at the Doheny Eye Centers between 2015 and 2017. All eligible patients had one 6 x 6 mm OCTA scan acquired during the first visit (considered as baseline) and two fovea-centered 512 x 128 macular cubes (6 x 6 mm) acquired at baseline and after a minimum of 12 months.

Main outcome measures

The fundus images from the OCT volumes were used to manually delineate the GA area and calculate the yGR after square root transformation. The en-face angiogram at the level of the CC was analyzed for the percentage of flow voids (FV) outside the atrophic lesion (FV_OUT) and in the para- and peri-atrophy regions (FV₅₀₀ and FV₁₀₀₀ respectively; two concentric 500 μm wide rings around the atrophy edge). These values, together with the difference between FV₅₀₀ and FV₁₀₀₀ (ΔFV), were then correlated with the corresponding yGR.

Results

Thirty-three eyes of 23 patients were eligible for the analysis. The mean yGR was 0.23 ± 0.17 mm/years.

At baseline, the mean FV_OUT was 41.86 ± 2.71%, while FV₅₀₀ and FV₁₀₀₀ were 46.4 ± 4.17% and 42.51 ± 2.65% respectively. The mean ΔFV was 3.89 ± 2.6%. While in the univariable analysis, the yGR was significantly associated with FV₅₀₀ and with ΔFV (both p < 0.001), in multivariable model the association remained significant only with ΔFV (p < 0.001).

Conclusions

Our study reports a correlation between the CC flow impairment around the atrophic lesions and their yGR in patients with GA. If replicated in future longitudinal studies, the choriocapillaris FV in the para-and peri-atrophy regions may prove to be useful parameters for evaluating the prognosis of these eyes.

Antibiotic use practice and predictors of hospital outcome among patients with systemic bacterial infection: Identifying targets for antibiotic and health care resource stewardship

BACKGROUND

Malpractice and excess use of antimicrobials have been associated with multiple costs, including the development of resistant bacteria, which has become a threat to the human health. The aim of this study, therefore, was to assess the antibiotic use practice and to identify predictors of hospital outcome to uncover targets for stewardship.

METHODS

An Institution-based prospective observational study was performed from 9 April to 7 July 2014 in the internal medicine wards of Tikur Anbessa Specialized Hospital. Patients with suspected systemic bacterial infections during this period were strictly followed and data were abstracted using data abstraction format. Descriptive statistics and binary logistic regression were used for statistical analysis.

RESULTS

About half of the attended patients had suspected systemic bacterial infections, in which pneumonia is the most common. Cephalosporins were the most widely prescribed class of drugs in all the wards. Initial antibiotics were empiric in almost all of the cases. About 28% of the ward and 59% of the ICU patients died during the in-hospital stay. The mean length of stay (LoS) was 18.5+12.2 in the wards and 8.9+4.9 days in the ICU. Whilst digestive disease (AOR = 6.94, 95% CI: 2.24, 21.49), different signs and symptoms of disease (AOR = 2.43, 95% CI: 1.30, 4.56), sepsis (AOR = 2.59, 95% CI: 1.12, 5.99) and vancomycin use (AOR = 2.60, 95% CI: 1.30, 5.21) were independent positive predictors, antibiotic days (> 10) (AOR = 0.37, 95% CI: 0.20, 0.70) was a negative predictor for mortality. On the other hand, hospital-acquired infection (AOR = 3.01, 95% CI: 1.05, 8.62), beyond the median antibiotic days (> 10) (AOR = 4.05, 95% CI: 1.96, 8.37) and agent days beyond 21 days (AOR = 2.18, 95% CI: 1.01-4.68) were independently associated with prolonged LoS.

CONCLUSION

Generally, this observation entails an appropriate infection management and antimicrobial use policy. Any future policy should better start by addressing cases like pneumonia, and sepsis and drugs like cephalosporins.

Clinical Outcomes of Patients with Advanced Cancer and Pre-Existing Autoimmune Diseases Treated with Anti-Programmed Death-1 Immunotherapy: A Real-World Transverse Study

BACKGROUND

Patients with a history of autoimmune diseases (AIDs) have not usually been included in clinical trials with immune checkpoint inhibitors.

MATERIALS AND METHODS

Consecutive patients with advanced cancer, treated with anti-programmed death-1 (PD-1) agents, were evaluated according to the presence of pre-existing AIDs. The incidence of immune-related adverse events (irAEs) and clinical outcomes were compared among subgroups.

RESULTS

A total of 751 patients were enrolled; median age was 69 years. Primary tumors were as follows: non-small cell lung cancer, 492 (65.5%); melanoma, 159 (21.2%); kidney cancer, 94 (12.5%); and others, 6 (0.8%). Male/female ratio was 499/252. Eighty-five patients (11.3%) had pre-existing AIDs, further differentiated in clinically active (17.6%) and inactive (82.4%). Among patients with pre-existing AIDs, incidence of irAEs of any grade was significantly higher when compared with patients without AIDs (65.9% vs. 39.9%). At multivariate analysis, both inactive (p = .0005) and active pre-existing AIDs (p = .0162), female sex (p = .0004), and Eastern Cooperative Oncology Group Performance Status <2 (p = .0030) were significantly related to a higher incidence of irAEs of any grade. No significant differences were observed regarding grade 3/4 irAEs and objective response rate among subgroups. Pre-existing AIDs were not significantly related with progression-free survival and overall survival.

CONCLUSION

This study quantifies the increased risk of developing irAEs in patients with pre-existing AIDs who had to be treated with anti-PD-1 immunotherapy. Nevertheless, the incidence of grade 3/4 irAEs is not significantly higher when compared with control population. The finding of a greater incidence of irAEs among female patients ranks among the "hot topics" in gender-related differences in immuno-oncology.

IMPLICATIONS FOR PRACTICE

Patients with a history of autoimmune diseases (AIDs) have not usually been included in clinical trials with immune checkpoint inhibitors but are frequent in clinical practice. This study quantifies the increased risk of developing immune-related adverse events (irAEs) in patients with pre-existing AIDs who had to be treated with anti-programmed death-1 immunotherapy. Nevertheless, their toxicities are mild and the incidence of grade 3/4 irAEs is not significantly higher compared with those of controls. These results will help clinicians in everyday practice, improving their ability to offer a proper counselling to patients, in order to offer an immunotherapy treatment even to patients with pre-existing autoimmune disease.

Risk factors affecting hospital stay among patients undergoing colon cancer surgery: a prospective cohort study

PURPOSE

To identify and validate risk factors that contribute to prolonged length of hospital stay (LOS) in patients undergoing resection for colorectal cancer.

METHODS

This prospective cohort study included 1955 patients admitted to 22 hospitals for primary resection of colorectal cancer. Multivariate analyses were used to identify and validate risk factors, randomizing patients into a derivation and a validation cohort. Multiple correspondence and cluster analysis were performed to identify clinical subtypes based on LOS.

RESULTS

The strongest independent predictors of prolonged LOS were postoperative reintervention, surgical site infection, open surgery, and distant metastasis. The multiple correspondence and cluster analysis provided three groups of patients in relation to prolonged LOS: patients with the longest LOS included the highest percentage of patients with open surgery, distant metastasis, deep surgical site infections, emergency admissions, additional diagnostic factors, and highly contaminated surgical sites. Patients with prolonged LOS (> 14 days) were more likely to develop adverse outcomes within 30 days after discharge.

CONCLUSIONS

Patients undergoing resection of colorectal cancer cluster into different groups based on LOS of the index admission. Those with prolonged LOS were more likely to develop adverse outcomes within 30 days after discharge. Some of the strongest independent predictors of prolonged LOS, such as surgical infections or open surgery, could be modified to reduce LOS and, in turn, other adverse outcomes.

TRIAL REGISTRATION

NCT02488161.

Simplified end stage renal failure risk prediction model for the low-risk general population with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) contributes significant morbidity and mortality among Asians; hence interventions should focus on those most at-risk of progression. However, current end stage renal failure (ESRF) risk stratification tools are complex and not validated in multi-ethnic Asians. We hence aimed to develop an ESRF risk prediction model by taking into account ethnic differences within a fairly homogenous socioeconomic setting and using parameters readily accessible to primary care clinicians managing the vast majority of patients with CKD.

METHODS

We performed a prospective cohort study of 1970 adults with CKD estimated glomerular filtration rate <60 ml/min/1.73m2 or albuminuria >30 mg/g from the population-based Singapore Epidemiology of Eye Diseases study (n = 10,033). Outcome was incident ESRF, ascertained by linkage to the Singapore Renal Registry until 2015.

RESULTS

Mean follow up was 8.5 ± 1.8 years and ESRF occurred in 32 individuals (1.6%). ESRF incidence rates were 2.8, 0.8 and 2.6 per 1000 patient years in Malays, Indians and Chinese respectively. The best ESRF prediction model included age, gender, eGFR and albuminuria (calibration χ2 = 0.45, P = 0.93; C-statistic 0.933, 95% confidence interval (CI) 0.889-0.978, p = 0.01; AIC 356). Addition of ethnicity improved discrimination marginally (C statistic 0.942, 95% CI 0.903-0.981, p = 0.21). Addition of clinical variables such as diabetes and hyperlipidemia did not improve model performance significantly.

CONCLUSION

We affirmed the utility of commonly available clinical information (age, gender, eGFR and UACR) in prognosticating ESRF for multi-ethnic Asians with CKD.

Do hospitals influence geographic variation in admission for preventable hospitalisation? A data linkage study in New South Wales, Australia

OBJECTIVE

Preventable hospitalisations are used internationally as a performance indicator for primary care, but the influence of other health system factors remains poorly understood. This study investigated between-hospital variation in rates of preventable hospitalisation.

SETTING

Linked health survey and hospital admissions data for a cohort study of 266 826 people aged over 45 years in the state of New South Wales, Australia.

METHOD

Between-hospital variation in preventable hospitalisation was quantified using cross-classified multiple-membership multilevel Poisson models, adjusted for personal sociodemographic, health and area-level contextual characteristics. Variation was also explored for two conditions unlikely to be influenced by discretionary admission practice: emergency admissions for acute myocardial infarction (AMI) and hip fracture.

RESULTS

We found significant between-hospital variation in adjusted rates of preventable hospitalisation, with hospitals varying on average 26% from the state mean. Patients served more by community and multipurpose facilities (smaller facilities primarily in rural areas) had higher rates of preventable hospitalisation. Community hospitals had the greatest between-hospital variation, and included the facilities with the highest rates of preventable hospitalisation. There was comparatively little between-hospital variation in rates of admission for AMI and hip fracture.

CONCLUSIONS

Geographic variation in preventable hospitalisation is determined in part by hospitals, reflecting different roles played by community and multipurpose facilities, compared with major and principal referral hospitals, within the community. Care should be taken when interpreting the indicator simply as a performance measure for primary care.

[Elderly patients and atrial fibrillation: age alone should not be a contra-indication for anticoagulant treatment]

A significant proportion of elderly patients are not properly treated with anticoagulants. Here we describe the pros and cons of anticoagulant treatment in elderly patients with atrial fibrillation, illustrated by two cases. We discuss the sometimes difficult treatment decisions to be made in frail elderly patients, especially after they have suffered bleeding complications. Aspirin is now considered obsolete in the treatment of atrial fibrillation in the elderly.

Can mid-regional pro-adrenomedullin (MR-proADM) increase the prognostic accuracy of NEWS in predicting deterioration in patients admitted to hospital with mild to moderately severe illness? A prospective single-centre observational study

OBJECTIVE

To assess the value added to the National Early Warning Score (NEWS) by mid-regional pro-adrenomedullin (MR-proADM) blood level in predicting deterioration in mild to moderately ill people.

DESIGN

Prospective observational study.

SETTING

The Medical Admissions Suite of the Royal Victoria Infirmary, Newcastle.

PARTICIPANTS

300 adults with NEWS between 2 and 5 on admission. Exclusion criteria included receiving palliative care, or admitted for social reasons or self-harming. Patients were enrolled between September and December 2015, and followed up for 30 days after discharge.

OUTCOME MEASURE

The primary outcome measure was the proportion of patients who, within 72 hours, had an acuity increase, defined as any combination of an increase of at least 2 in the NEWS; transfer to a higher-dependency bed or monitored area; death; or for those discharged from hospital, readmission for medical reasons.

RESULTS

NEWS and MR-proADM together predicted acuity increase more accurately than NEWS alone, increasing the area under the curve (AUC) to 0.61 (95% CI 0.54 to 0.69) from 0.55 (95% CI 0.48 to 0.62). When the confounding effects of presence of chronic obstructive pulmonary disease or heart failure and interaction with MR-proADM were included, the prognostic accuracy further increased the AUC to 0.69 (95% CI 0.63 to 0.76).

CONCLUSIONS

MR-proADM is potentially a clinically useful biomarker for deterioration in patients admitted to hospital with a mild to moderately severe acute illness, that is, with NEWS between 2 and 5. As a growing number of National Health Service hospitals are routinely recording the NEWS on their clinical information systems, further research should assess the practicality and use of developing a decision aid based on admission NEWS, MR-proADM level, and possibly other clinical data and other biomarkers that could further improve prognostic accuracy.

Urinary Proteomics Profiles Are Useful for Detection of Cancer Biomarkers and Changes Induced by Therapeutic Procedures

Boron neutron capture therapy (BNCT) is a binary cancer treatment modality where two different agents (¹⁰B and thermal neutrons) have to be present to produce an effect. A dedicated trial design is necessary for early clinical trials. The concentration of ¹⁰B in tissues is an accepted surrogate to predict BNCT effects on tissues. Tissue, blood, and urines were sampled after infusion of two different boron carriers, namely BSH and BPA in the frame of the European Organisation for Research and Treatment of Cancer (EORTC) trial 11001. In this study, urine samples were used to identify protein profiles prior and after drug infusion during surgery. Here, an approach that is based on the mass spectrometry (MS)-based proteomic analysis of urine samples from head and neck squamous cell carcinoma (HNSCC) and thyroid cancer patients is presented. This method allowed the identification of several inflammation- and cancer-related proteins, which could serve as tumor biomarkers. In addition, changes in the urinary proteome during and after therapeutic interventions were detected. In particular, a reduction of three proteins that were involved in inflammation has been observed: Galectin-3 Binding Protein, CD44, and osteopontin. The present work represents a proof of principle to follow proteasome changes during complex treatments based on urine samples.

Hybrid multivariate pattern analysis combined with extreme learning machine for Alzheimer's dementia diagnosis using multi-measure rs-fMRI spatial patterns

Background

Early diagnosis of Alzheimer’s disease (AD) and Mild Cognitive Impairment (MCI) is essential for timely treatment. Machine learning and multivariate pattern analysis (MVPA) for the diagnosis of brain disorders are explicitly attracting attention in the neuroimaging community. In this paper, we propose a voxel-wise discriminative framework applied to multi-measure resting-state fMRI (rs-fMRI) that integrates hybrid MVPA and extreme learning machine (ELM) for the automated discrimination of AD and MCI from the cognitive normal (CN) state.

Materials and methods

We used two rs-fMRI cohorts: the public Alzheimer’s disease Neuroimaging Initiative database (ADNI2) and an in-house Alzheimer’s disease cohort from South Korea, both including individuals with AD, MCI, and normal controls. After extracting three-dimensional (3-D) patterns measuring regional coherence and functional connectivity during the resting state, we performed univariate statistical t-tests to generate a 3-D mask that retained only voxels showing significant changes. Given the initial univariate features, to enhance discriminative patterns, we implemented MVPA feature reduction using support vector machine-recursive feature elimination (SVM-RFE), and least absolute shrinkage and selection operator (LASSO), in combination with the univariate t-test. Classifications were performed by an ELM, and its efficiency was compared to linear and nonlinear (radial basis function) SVMs.

Results

The maximal accuracies achieved by the method in the ADNI2 cohort were 98.86% (p<0.001) and 98.57% (p<0.001) for AD and MCI vs. CN, respectively. In the in-house cohort, the same accuracies were 98.70% (p<0.001) and 94.16% (p<0.001).

Conclusion

From a clinical perspective, combining extreme learning machine and hybrid MVPA applied on concatenations of multiple rs-fMRI biomarkers can potentially assist the clinicians in AD and MCI diagnosis.

Avascular osteonecrosis in kidney transplant recipients: Risk factors in a recent cohort study and evaluation of the role of secondary hyperparathyroidism

Avascular osteonecrosis (AVN) is a bone complication that indicates poor functional prognosis. Modern immunosuppressive and steroid-sparing drugs have significantly lowered the occurrence of AVN after kidney transplantation (KT). However, recent data on its incidence rates and risk factors are lacking. Using a large, recent cohort, we sought to investigate AVN incidence and risk factors, with a special focus on mineral and bone disorders. We conducted a cohort study in 805 patients who underwent KT between 2004 and 2014. AVN was identified in 32 patients (4%): before KT in 15 (1.8%) and after KT in 18 (2.2%) cases, including one patient with both. In the group with post-KT AVN, the median time intervals from KT to 1) first symptoms and 2) AVN diagnosis were 12 months [1–99] and 20 months [4–100], respectively. Being overweight/obese, having pre-transplant diabetes or hyperparathyroidism at transplantation, developing acute rejection, and receiving higher cumulative corticosteroid doses were associated with AVN occurrence. Multivariate analysis revealed that BMI ≥ 26 kg/m² and higher cumulative corticosteroid doses were predictive of AVN. In conclusion, overweight/obesity is a strong risk factor for AVN. Despite a low maintenance dose, the use of corticosteroids—mostly for treatment of acute rejection—remains an independent risk factor.

Does aquatic exercise improve commonly reported predisposing risk factors to falls within the elderly? A systematic review

BACKGROUND

According to the World Health Organization, the elderly are at the highest risk of injury or death from a fall. Age-related changes in strength, balance and flexibility are degenerative factors that may increase the risk of falling, and an aquatic training may offer a favourable environment to improve these modifiable risk factors.

METHODS

A systematic review was conducted to assess the potential preventative role of aquatic exercise for reducing the risk of falls in the elderly by improving predisposing risk factors. Electronic databases and reference lists of pertinent articles published between 2005 and 2018 were searched. Randomized controlled trials (RCTs) that directly or indirectly addressed the effect of aquatic exercise for the prevention of falls in healthy participants were included within the synthesis. Studies were included if they were reported between January 2005 and May 2018 within a population aged between 60 and 90 years old that were without exercise-effecting comorbidities. Data related to participant demographics, study design, methodology, interventions and outcomes was extracted by one reviewer. Methodological quality assessment was independently performed by two reviewers using the PEDro (Physiotherapy Evidence Database) scale.

RESULTS

Fourteen trials met the inclusion criteria. Exercise intervention duration and frequency varied from 2 to 24 weeks, from 2 to 3 times per week, from 40 to 90 min per session. Fall rate was not reported in any of the studies analysed. However, aquatic exercise improved key predisposing physical fitness components that are modifiable and internal risk factors for falling.

CONCLUSIONS

There is limited, low-quality evidence to support the use of aquatic exercise for improving physiological components that are risk factors for falling. Although the evidence is limited, and many interventions are not well described, these results should be considered by health and exercise professionals when making evidence-based, clinical decisions regarding training programmes to reduce the risk of falling.

Safety and Feasibility of Linear Stapling Device with Bioabsorbable Polyglycolic Acid Sheet for Duodenal Closure in Gastric Cancer Surgery: A Multi-institutional Phase II Study

BACKGROUND

Duodenal stump fistula (DSF) after gastrectomy is of low frequency but a critical complication in gastric cancer surgery. Manual oversewing for reinforcement of the duodenal stump is not applicable when free longitudinal margin is short and has technical difficulties in laparoscopic surgery. This trial evaluated the safety and feasibility of using a linear stapler with bioabsorbable polyglycolic acid (PGA) sheet for duodenal stump closure and reinforcement in gastric cancer surgery.

METHODS

This multi-institutional, prospective phase II trial included gastric cancer patients who were scheduled to undergo distal or total gastrectomy with R-Y reconstruction. In all cases, duodenum was transected using a linear stapler with PGA sheet. The primary endpoint was the incidence of postoperative DSF. Sample size was set at 100 patients considering an expected value of 3% and threshold value of 8% with one-sided testing at a 10% significance level.

RESULTS

Between June 2014 and June 2015, a total of 100 patients were registered in this trial. Postoperative DSF was observed in two cases (2.0%, 90% CI 0.4-6.2%) which was developed on postoperative days 13 and 20. Intraoperative bleeding at the duodenal stump staple line was observed in one case but was easily controlled without additional suturing. Postoperative bleeding was not observed in any of the cases.

CONCLUSION

This study suggested that the use of PGA sheet as a reinforcement material for closure of the duodenal stump during gastrectomy for gastric cancer is both safe and feasible. Trial registration number UMIN 000014398.

Body mass index trajectories preceding first report of poor self-rated health: A longitudinal case-control analysis of the English Longitudinal Study of Ageing

Background

Studies have consistently found that obesity is associated with poor self-rated health, but how body mass index (BMI) developed in the lead up to poor self-rated health is unknown.

Methods

We nested a longitudinal case-control study in the English Longitudinal Study of Ageing (1998–2015) to investigate BMI trajectories in the years preceding a first self-report of poor health. Participants rated their health at each data collection; every other collection included a BMI assessment by a nurse. Case status was defined as a first report of poor health during follow-up. Three age- and sex-matched controls were identified per case using density sampling. BMI trajectories were fitted to time backwards prior to first report of poor health using mixed-effects models. Age and sex were potential modifiers. We conducted subgroup analyses of those not reporting certain chronic diseases or smoking.

Results

We identified 732 cases and 2195 controls. Age, but not sex, modified the association between BMI and self-rated health. Participants reporting poor health at age 60 had a 1.5 kg/m² (95%CI: 0.8 to 2.1) higher BMI at the time of reporting than controls, and their BMI had previously increased markedly (1.3 kg/m² 95%CI: 0.9 to 1.8 over ten years). After age 75, cases no longer had higher BMI than controls, and their BMI had decreased sharply prior to reporting poor health (e.g. -2.0 kg/m² 95%CI: -2.6 to -1.5 per decade on average for those reporting poor health at age 90). Age was also an effect modifier among those without diabetes, however BMI trajectories were more similar among the middle-aged. The subgroup analysis of those without cardiovascular disease, cancer and chronic lung disease showed similar results to the main findings.

Conclusion

Development of BMI was associated with poor self-rated health; however, the nature of the association depended markedly on age.

A Prospective Study Identifying a Change in Energy and Protein Intake of Older Adults during Inpatient Rehabilitation

Understanding older patients' dietary intake patterns may improve the timing of strategies to address hospital malnutrition. The aims of this study were to explore longitudinally the change in daily energy (kJ/day) and protein (g/day) intake, and associated factors. Data were derived using a 5-point scale to visually estimate plate waste, and known nutrient composition data. Analyses determined the change in intake between admission and day 14, and admission, day 14 and day 28, respectively. Data were available for 39 participants between admission and day 14 (median (interquartile range) age 82 (78⁻87) years; 54% male) and 12 participants between admission, day 14 and day 28 (median (IQR) age 79 (69⁻84) years; 58% male). From admission to day 14 there was a significant increase in the mean (SD) daily intake of energy (6177 (1879) kJ/day vs. 7213 (1903), p < 0.001) and protein (63.7 (23) g/day vs. 76.4 (23.0) g/day, p = 0.003) but no change from admission to day 14 to day 28. There was a significant inverse relationship between amount consumed at admission and change in intake. Variability in elderly patients' intake over time has implications for the timing of nutritional care and data collection in research studies.