Disseminating a Clinically Effective Physical Activity Program to Preserve Mobility in a Community Setting for Older Adults

BACKGROUND

As the population of older adults continues to increase, the dissemination of strategies to maintain independence of older persons is of critical public health importance. Recent large-scale clinical trial evidence has definitively shown intervention of moderate-intensity physical activity (PA) reduces major mobility disability in at-risk older adults. However, it remains unknown whether structured PA interventions, with demonstrated efficacy in controlled, clinical environments, can be successfully disseminated into community settings to benefit wider populations of older adults.

OBJECTIVE

To assess the dissemination of an evidence-based PA program for older adults by evaluating program participation and its impact on mobility, strength and quality of life.

SETTING

An urban senior center.

PARTICIPANTS

Fifty older adults (71.2 ± 8 years aged; BMI: 30.1 ± 7 kg/m2).

INTERVENTION

Average of 8.0 ± 1.8 months of participation in the Fit-4-Life Program, a community-based PA and nutrition counseling intervention.

MEASUREMENTS

Mobility (Short Physical Performance Battery (SPPB)), self-reported physical activity (CHAMPS questionnaire), leg strength, grip strength, and quality of life (Quality of Well-Being Self-Administered (QWB-SA) scale) were assessed at baseline and follow-up.

RESULTS

Mean attendance was 55.8%. Fourteen participants were lost to follow-up. Those who dropped-out engaged in less PA at baseline (78 ± 108 mins/wk) compared to those who completed follow-up (203 ± 177 mins/wk, P=0.01). Participants exhibited sustained increases of PA (65 ± 153 mins/wk, P= 0.08), and there were meaningful improvements in SPPB (0.5 ± 0.2, P< 0.01), knee extensor strength (2.6 ± 4.4 kg, P< 0.01) and QWB-SA (0.04 ± 0.09, P= 0.05).

CONCLUSION

The dissemination of a clinically efficacious PA intervention into a community-based setting can improve mobility, strength and quality of life for older adults. This knowledge may be helpful for the design and implementation of larger-scale PA intervention studies designed to preserve mobility in older adults within community-based settings.

A widespread bacterial phenazine forms S-conjugates with biogenic thiols and crosslinks proteins

Phenazines are redox-active compounds produced by a range of bacteria, including many pathogens. Endowed with various biological activities, these ubiquitous N-heterocycles are well known for their ability to generate reactive oxygen species by redox cycling. Phenazines may lead to an irreversible depletion of glutathione, but a detailed mechanism has remained elusive. Furthermore, it is not understood why phenazines have so many protein targets and cause protein misfolding as well as their aggregation. Here we report the discovery of unprecedented conjugates (panphenazines A, B) of panthetheine and phenazine-1-carboxylic (PCA) acid from a Kitasatospora sp., which prompted us to investigate their biogenesis. We found that PCA reacts with diverse biogenic thiols under radical-forming conditions, which provides a plausible model for irreversible glutathione depletion. To evaluate the scope of the reaction in cells we designed biotin and rhodamine conjugates for protein labelling and examined their covalent fusion with model proteins (ketosynthase, carbonic anhydrase III, albumin). Our results reveal important, yet overlooked biological roles of phenazines and show for the first time their function in protein conjugation and crosslinking.

Haematological values of the multimammate mouse Praomys (Mastomys) Natalensis

The haematological estimates on 55 multimammate mice, Praomys (Mastomys) natalensis, are recorded. The data are presented as means, standard deviations and ranges or confidence limits.

Cultural Perceptions of Finnish Nursing Students Regarding People and Nurses of the United States: A Pilot Study

This pilot study measures cultural awareness through perceptions of 139 Finnish nursing students regarding American people and nurses. Inquiry was guided by cultural dimensions depicted in Leininger’s Sunrise Model. Statements of highest agreement were that: U.S. citizens frequently initiate lawsuits, have strong national identity, eagerly try new technological equipment, U.S. nurses have less authority than physicians, the U.S. shares technological advances with Third World countries. Statements of lowest agreement were that health care is available to all U.S. citizens, U.S. people live healthy lifestyles, U.S. nurses have knowledge of other cultures and knowledge of international health care issues, and U.S. citizens are law abiding. Almost half of the responses indicated neither agree nor disagree, with means between 2.7 and 3.3. Responses of Finnish students indicated stereotypical views of U.S. citizens and nurses.

Home Nutrition Support: Ethics and Reimbursement

Ethical dilemmas challenge providers on both sides of the hospital and clinic doors. In addition to establishing the nutrition care plan and guiding the client into the home setting with safe and effective parenteral or enteral nutrition therapy, procuring home nutrition support involves meeting documentation requirements and verifying that clients meet reimbursement criteria for home therapy based on third-party payer criteria. Providers have entered a realm for which training has been scarce and they face moral and ethical dilemmas involving serving as patient advocates, possibly stretching the truth to fit the clinical documentation to criteria vs maintaining professional integrity. Nutrition research and evidence-based practice have outpaced modifications to policies including Medicare's national and local coverage determinations, the bulk of which have not seen revisions in 32 years. This review elucidates clinical dilemmas and urges a political call to action to advocate for changes in current, outdated requirements for reimbursement. Given the current healthcare environment and trend toward expedited hospital stays, patients may be better served (and nourished) with revised guidelines.

Mortality from trauma haemorrhage and opportunities for improvement in transfusion practice

Background

The aim of this study was to describe the prevalence, patterns of blood use and outcomes of major haemorrhage in trauma.

Methods

This was a prospective observational study from 22 hospitals in the UK, including both major trauma centres and smaller trauma units. Eligible patients received at least 4 units of packed red blood cells (PRBCs) in the first 24 h of admission with activation of the massive haemorrhage protocol. Case notes, transfusion charts, blood bank records and copies of prescription/theatre charts were accessed and reviewed centrally. Study outcomes were: use of blood components, critical care during hospital stay, and mortality at 24 h, 30 days and 1 year. Data were used to estimate the national trauma haemorrhage incidence.

Results

A total of 442 patients were identified during a median enrolment interval of 20 (range 7–24) months. Based on this, the national incidence of trauma haemorrhage was estimated to be 83 per million. The median age of patients in the study cohort was 38 years and 73·8 per cent were men. The incidence of major haemorrhage increased markedly in patients aged over 65 years. Thirty-six deaths within 24 h of admission occurred within the first 3 h. At 24 h, 79 patients (17·9 per cent) had died, but mortality continued to rise even after discharge. Patients who received a cumulative ratio of fresh frozen plasma to PRBCs of at least 1 : 2 had lower rates of death than those who received a lower ratio. There were delays in administration of blood. Platelets and cryoprecipitate were either not given, or transfused well after initial resuscitation.

Conclusion

There is a high burden of trauma haemorrhage that affects all age groups. Research is required to understand the reasons for death after the first 24 h and barriers to timely transfusion support.

ProCAID: A phase I clinical trial to combine the AKT inhibitor AZD5363 with docetaxel and prednisolone (DP) chemotherapy for metastatic castration resistant prostate cancer (mCRPC)

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Background: DP extends survival in mCRPC. However emergent clinical resistance is effectively inevitable. Serine/threonine protein kinase AKT (protein kinase B) pathway activation is highly prevalent in mCRPC contributing to disease progression and DP therapeutic resistance. AZD5363 is a potent oral pan-AKT inhibitor. Pre-clinical data suggest activity in mCRPC and synergy with docetaxel. This phase I trial was to develop a DP/AZD5363 combination in mCRPC. Methods: Eligibility included chemotherapy naive histologically/cytologically proven measurable/evaluable mCRPC, PSA or radiographic disease progression, ECOG performance status 0 or 1, serum testosterone <1.7 nmol/L. Treatment comprised DP up to 10 cycles (75 mg/m2, IV, day 1; prednisolone 5 mg BID, PO, day 1–21) and AZD5363 to disease progression. Planned AZD5363 dose levels were 320 mg (DL1), 400 mg (DL2) and 480 mg (DL3), BID, PO, 4 days on/3 days off, from cycle 1, day 2. We utilised a conventional 3+3 dose escalation to determine a recommended phase II dose (RP2D) for AZD5363 combined with DP according to defined dose limiting toxicity (DLT) using CTCAEv4. Results: 10 patients were recruited (4 DL1, 6 DL2), median age 67.5 (Range: 56-72). A median of 6.5 cycles (Range: 3-10) of DP and 4 cycles (Range: 1-13) of AZD5363 were administered. No DLTs were seen in DL1. 2 patients in DL2 experienced DLTs (G3 rash, G3 diarrhoea). 7 pts (70%) had at least one G3/4 IMP-related AE with neutropenia (n=3) and maculo-papular rash (n=3) the most common. G3/4 AEs considered related to AZD5363 occurred in 3 patients (0 DL1, 3 DL2) including maculo-papular rash, diarrhoea and neutropenia. Transient hyperglycaemia occurred in all patients (Random glucose C1D2 pre dose mean 6.0 mmol/L, 2 hour mean 8.7 mmol/L, 4 hour mean 9.5 mmol/L, 8 hour mean 6.5 mmol/L). Conclusions:The RP2D for AZD5363 is 320 mg bd 4 days on/3 days off in combination with full dose DP for mCRPC. A placebo controlled randomised phase II trial for this approach has commenced recruitment. This work was supported by CRUK [C9317/A16029]. CRUK Reference: CRUK/12/042. This research was conducted with support from the Investigator-Sponsored Study Collaboration between AstraZeneca and the National Cancer Research Network. Clinical trial information: NCT02121639.

Comparison of sedation and general anaesthesia for transcatheter aortic valve implantation on cerebral oxygen saturation and neurocognitive outcome†

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a treatment strategy for patients with severe aortic stenosis. Although general anaesthesia (TAVI-GA) and sedation (TAVI-S) have previously been described for TAVI, the difference in safety and efficacy of both methods has not been studied in a randomized trial.

METHODS

The INSERT trial was a single centre, controlled parallel-group trial with balanced randomization. Sixty-six patients (68-94 yr) with acquired aortic stenosis undergoing transfemoral CoreValve™ were assigned to TAVI-GA or TAVI-S. Comparable operative risk was determined from risk-scores (EUROscore, STS-Score). Monitoring and anaesthetic drugs were standardized. Near-Infrared-Spectroscopy was used to monitor cerebral-oxymetry blinded. Primary outcome was the perioperative cumulative cerebral desaturation. As secondary outcomes, changes in neurocognitive function and respiratory and haemodynamic adverse events were evaluated.

RESULTS

Of 66 included patients, 62 (TAVI-GA: n=31, TAVI-S: n=31) were finally analysed. Baseline characteristics were comparable. In 24 patients (39%) cerebral desaturation was observed. Cumulative cerebral desaturation was comparable (TAVI-GA:(median [IQR]) (0[0/1308] s%) vs. TAVI-S:(0[0/276] s%); P=0.505) between the groups. Neurocognitive function did not change within and between groups. Adverse events were more frequently observed in TAVI-S patients (P<0.001). Bradypnoea (n=16, 52%) and the need for airway manoeuvres (n=11, 36%) or bag-mask-ventilation (n=6, 19%) were the most common respiratory adverse events.

CONCLUSIONS

Cerebral desaturation occurred in both patient groups, but there was no significant difference between the two groups. Based on primary outcome, both methods were shown to be comparable. Neurocognitive outcome was similar. The higher incidence of adverse events in the sedation group suggests a potential advantage of general anaesthesia.

CLINICAL TRIAL REGISTRATION

NCT 01251328.

Characterisation of sleep disturbances in postural orthostatic tachycardia syndrome: a polysomnography-based study

BACKGROUND AND AIM

Postural orthostatic tachycardia syndrome (PoTS) has been frequently associated with sleep disturbances but objective sleep data are lacking. In addition, although regional autonomic denervation has been described, less is known about autonomic nervous activity overnight in these patients.

PATIENTS/METHODS

A full polysomnography and heart rate variability were performed on 37 patients diagnosed with PoTS . In addition, a multiple sleep latency test (MSLT) was conducted on a subgroup of patients with excessive daytime sleepiness.

RESULTS

The polysomnographic data did not show major pathological findings except the percentage spent in rapid eye movement (REM) sleep which was slightly reduced at 18.4%. The MSLT did not confirm excessive daytime sleepiness as median mean sleep latency was 14.4 min (11.8-17.5). When comparing patients with and without subjective daytime sleepiness, it was found that the latter had a reduced parasympathetic activation at night as expressed by the average high frequency [6936.5 ms(2) (6028.2-8675.5) vs. 4689.5 (3922.7-7685.2) p < 0.05].

CONCLUSION

Patients with PoTS do not exhibit polysomnographic findings consistent with relevant sleep pathologies nor objective daytime sleepiness. Subjective daytime sleepiness is associated with enhanced activation of the parasympathetic nervous system.

Auditory and visual localization accuracy in young children and adults

OBJECTIVE

This study aimed to measure and compare sound and light source localization ability in young children and adults who have normal hearing and normal/corrected vision in order to determine the extent to which age, type of stimuli, and stimulus order affects sound localization accuracy.

METHODS

Two experiments were conducted. The first involved a group of adults only. The second involved a group of 30 children aged 3 to 5 years. Testing occurred in a sound-treated booth containing a semi-circular array of 15 loudspeakers set at 10° intervals from -70° to 70° azimuth. Each loudspeaker had a tiny light bulb and a small picture fastened underneath. Seven of the loudspeakers were used to randomly test sound and light source identification. The sound stimulus was the word "baseball". The light stimulus was a flashing of a light bulb triggered by the digital signal of the word "baseball". Each participant was asked to face 0° azimuth, and identify the location of the test stimulus upon presentation. Adults used a computer mouse to click on an icon; children responded by verbally naming or walking toward the picture underneath the corresponding loudspeaker or light. A mixed experimental design using repeated measures was used to determine the effect of age and stimulus type on localization accuracy in children and adults. A mixed experimental design was used to compare the effect of stimulus order (light first/last) and varying or fixed intensity sound on localization accuracy in children and adults.

RESULTS

Localization accuracy was significantly better for light stimuli than sound stimuli for children and adults. Children, compared to adults, showed significantly greater localization errors for audition. Three-year-old children had significantly greater sound localization errors compared to 4- and 5-year olds. Adults performed better on the sound localization task when the light localization task occurred first.

CONCLUSIONS

Young children can understand and attend to localization tasks, but show poorer localization accuracy than adults in sound localization. This may be a reflection of differences in sensory modality development and/or central processes in young children, compared to adults.

The pet factor--companion animals as a conduit for getting to know people, friendship formation and social support

BACKGROUND

While companion animals have been previously identified as a direct source of companionship and support to their owners, their role as a catalyst for friendship formation or social support networks among humans has received little attention. This study investigated the indirect role of pets as facilitators for three dimensions of social relatedness; getting to know people, friendship formation and social support networks.

METHODS

A telephone survey of randomly selected residents in four cities, one in Australia (Perth; n = 704) and three in the U.S. (San Diego, n = 690; Portland, n = 634; Nashville, n = 664) was conducted. All participants were asked about getting to know people within their neighborhood. Pet owners were asked additional questions about the type/s of pet/s they owned, whether they had formed friendships as a result of their pet, and if they had received any of four different types of social support from the people they met through their pet.

RESULTS

Pet owners were significantly more likely to get to know people in their neighborhood than non-pet owners (OR 1.61; 95%CI: 1.30, 1.99). When analyzed by site, this relationship was significant for Perth, San Diego and Nashville. Among pet owners, dog owners in the three U.S. cities (but not Perth) were significantly more likely than owners of other types of pets to regard people whom they met through their pet as a friend (OR 2.59; 95%CI: 1.94, 3.46). Around 40% of pet owners reported receiving one or more types of social support (i.e. emotional, informational, appraisal, instrumental) via people they met through their pet.

CONCLUSION

This research suggests companion animals can be a catalyst for several dimensions of human social relationships in neighborhood settings, ranging from incidental social interaction and getting to know people, through to formation of new friendships. For many pet owners, their pets also facilitated relationships from which they derived tangible forms of social support, both of a practical and emotionally supportive nature. Given growing evidence for social isolation as a risk factor for mental health, and, conversely, friendships and social support as protective factors for individual and community well-being, pets may be an important factor in developing healthy neighborhoods.

Effects of parathyroid hormone on glucose production by the liver

The present studies demonstrate a stimulatory effect of intact parathyroid hormone on hepatic glucose production in vivo. This increased glucose production was accompanied by augmented alanine uptake by the liver. In addition, PTH increased the conversion of 14C-alanine to 14C-glucose. These results suggest that the increased hepatic release of glucose produced by PTH is mediated in part by increased gluconeogenesis. On the other hand, the synthetic 1-34 amino terminal fragment of PTH, which is not extracted by the liver, did not stimulate hepatic glucose production.

Initial resuscitation and management of pediatric septic shock

The pediatric sepsis syndrome remains a common cause of morbidity, mortality, and health care utilization costs worldwide. The initial resuscitation and management of pediatric sepsis is focused on 1) rapid recognition of abnormal tissue perfusion and restoration of adequate cardiovascular function; 2) eradication of the inciting invasive infection, including prompt administration of empiric broad-spectrum antimicrobial medications; and 3) supportive care of organ system dysfunction. Efforts to improve early and aggressive initial resuscitation and ongoing management strategies have improved outcomes in pediatric severe sepsis and septic shock, though many questions still remain as to the optimal therapeutic strategies for many patients. In this article, we will briefly review the definitions, epidemiology, clinical manifestations, and pathophysiology of sepsis and provide an extensive overview of both current and novel therapeutic strategies used to resuscitate and manage pediatric patients with severe sepsis and septic shock.