Muscle Function and Sarcopenia: Clinical Implications of Recent Research

[Clinical acute and emergency medicine curriculum-focus on internal medicine : Recommendations for advanced training in internal medicine in the emergency department]

In Germany, physicians qualify for emergency medicine by combining a specialty medical training-e.g. internal medicine-with advanced training in emergency medicine according to the statutes of the State Chambers of Physicians largely based upon the Guideline Regulations on Specialty Training of the German Medical Association. Internal medicine and their associated subspecialities represent an important column of emergency medicine. For the internal medicine aspects of emergency medicine, this curriculum presents an overview of knowledge, skills (competence levels I-III) as well as behaviours and attitudes allowing for the best treatment of patients. These include general aspects (structure and process quality, primary diagnostics and therapy as well as indication for subsequent treatment; resuscitation room management; diagnostics and monitoring; general therapeutic measures; hygiene measures; and pharmacotherapy) and also specific aspects concerning angiology, endocrinology, diabetology and metabolism, gastroenterology, geriatric medicine, hematology and oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology and toxicology. Publications focussing on contents of advanced training are quoted in order to support this concept. The curriculum has primarily been written for internists for their advanced emergency training, but it may generally show practising emergency physicians the broad spectrum of internal medicine diseases or comorbidities presented by patients attending the emergency department.

Applying Evidence-based Principles to Guide Emergency Surgery in Older Adults

Although outcomes for older adults undergoing elective surgery are generally comparable to younger patients, outcomes associated with emergency surgery are poor. These adverse outcomes are in part because of the physiologic changes associated with aging, increased odds of comorbidities in older adults, and a lower probability of presenting with classic "red flag" physical examination findings. Existing evidence-based perioperative best practice guidelines perform better for elective compared with emergency surgery; so, decision making for older adults undergoing emergency surgery can be challenging for surgeons and other clinicians and may rely on subjective experience. To aid surgical decision making, clinicians should assess premorbid functional status, evaluate for the presence of geriatric syndromes, and consider social determinants of health. Documentation of care preferences and a surrogate decision maker are critical. In discussing the risks and benefits of surgery, patient-centered narrative formats with inclusion of geriatric-specific outcomes are important. Use of risk calculators can be meaningful, although limitations exist. After surgery, daily evaluation for common postoperative complications should be considered, as well as early discharge planning and palliative care consultation, if appropriate. The role of the geriatrician in emergency surgery for older adults may vary based on the acuity of patient presentation, but perioperative consultation and comanagement are strongly recommended to optimize care delivery and patient outcomes.

Assessing Additional Characteristics of Muscle Function With Digital Handgrip Dynamometry and Accelerometry: Framework for a Novel Handgrip Strength Protocol

Maximal handgrip strength (HGS) is a convenient and reliable, but incomplete, assessment of muscle function. Although low HGS is a powerful predictor of poor health, several limitations to maximal HGS exist. The predictive value of HGS is restricted because low HGS is associated with a wide range of unspecified health conditions, and other characteristics of muscle function aside from strength capacity are not evaluated. Current HGS protocol guidelines emphasize the ascertainment of maximal force, which is only a single muscle function characteristic. Muscle function is intrinsically multivariable, and assessing other attributes in addition to strength capacity will improve screenings for age-related disabilities and diseases. Digital handgrip dynamometers and accelerometers provide unique opportunities to examine several aspects of muscle function beyond strength capacity, while also maintaining procedural ease. Specifically, digital handgrip dynamometry and accelerometry can assess the rate of force development, submaximal force steadiness, fatigability, and task-specific tremoring. Moreover, HGS protocols can be easily refined to include an examination of strength asymmetry and bilateral strength. Therefore, evaluating muscle function with new HGS technologies and protocols may provide a more comprehensive assessment of muscle function beyond maximal strength, without sacrificing feasibility. This Special Article introduces a novel framework for assessing multiple attributes of muscle function with digital handgrip dynamometry, accelerometry, and refinements to current HGS protocols. Such framework may aid in the discovery of measures that better predict and explain age-related disability, biological aging, and the effects of comorbid diseases that are amenable to interventions. These additional HGS measures may also contribute to our understanding of concepts such as resilience. Using sophisticated HGS technologies that are currently available and modernizing protocols for developing a new muscle function assessment may help transform clinical practice by enhancing screenings that will better identify the onset and progression of the disabling process.