Adherence to the physical activity guideline beyond the recommended minimum weekly amount: impacts on indicators of physical function in older adults

Introduction

The extent to which additional health benefits of accumulating twice the minimum amount of time in moderate-to-vigorous physical activity (MVPA) affects indicators of physical function in older adults is unclear. Therefore, the aim of the present study was to assess indicators of physical function in older adults who accumulate at least 150 but less than 300 min/week of MVPA compared to those accumulating at least 300 min/week.

Methods

Indicators of physical function, including handgrip strength, 5 times sit-to-stand test (5-STS), squat jump and 6-min walk test (6MWT) were assessed in a sample of 193 older men (n = 71, 67 ± 2 years), and women (n = 122, 67 ± 2 years), who all accumulated at least 150 weekly minutes of MVPA. Time in MVPA was assessed by accelerometry during 1 week and engagement in muscle strengthening activities (MSA) was assessed by self-report. Protein intake was assessed by a food-frequency-questionnaire. Participants were classified as physically active (≥150 but <300 min of MVPA per week) or as highly physically active (≥300 min of MVPA per week).

Results

Factorial analysis of variance revealed that older adults accumulating at least 300 min of MVPA per week had a significantly (p < 0.05) better 6MWT performance and overall physical function compared to the less active group. These findings remained significant after further adjustment for MSA, sex, waist circumference and protein intake. In contrast, no significant differences in indicators of muscle strength were observed between the two groups.

Discussion

Adherence to twice the recommended minimum amount of weekly MVPA time is related to a better physical function, evidenced by a better walking performance compared to adherence to the minimum weekly amount of MVPA. This finding emphasizes the benefits of accumulating daily MVPA beyond the minimum recommended amount to optimize the ability to perform activities of daily living, thus reducing the burden of physical disability and related health-care costs.

Real-world long-term effects on blood pressure and other cardiovascular risk factors for patients in digital therapeutics

PURPOSE

Hypertension is a leading causeof premature death worldwide and a major public health problem. This study investigated the long-term effects (>1 year) of digital hypertension monitoring by home blood pressure (HBP) measurements in combination with individualized remote treatment via a Swedish Digital Therapeutics platform in a large patient population.

METHODS

The primary endpoint, HBP, and exploratory endpoints, BMI, alcohol consumption, stress level, physical activity, and smoking, were assessed every 3 months for 540 and 360 days, respectively, in 7752 Swedish primary hypertension patients. Patients received individualized medical treatments and lifestyle advice via asynchronous text-based communication in an app. Changes from baseline in endpoints were calculated for the whole population and for subgroups defined by baseline SBP ≥135 (high SBP), 125-135 (suboptimal SBP), 115-125 (optimal SBP), and <115 mmHg (low SBP).

RESULTS

After 360 days of treatment, the whole population showed a significant increase of 57% (from 37 to 58%) in the proportion of patients with controlled SBP (i.e. SBP of 115-135 mmHg). The largest reduction in SBP of 13.8 mmHg was observed for the high SBP subgroup, whereas for the low SBP subgroup, SBP increased by 13.4 mmHg. BP improved most in the first three months, and for both the high and low BP subgroups, the improvement continued during the 540-day study period. Significant beneficial changes were also observed for some exploratory endpoints including BMI and smoking.

CONCLUSIONS

In conclusion, the digital therapeutics platform was associated with significant improvement in BP control and associated risk factors, which were maintained over a longer period.

Waves in planetary dynamos

This Special Topic focuses on magnetohydrodynamic (MHD) processes in the deep interiors of planets, in which their fluid dynamos are in operation. The dynamo-generated, global, magnetic fields provide a background for our solar-terrestrial environment. Probing the processes within the dynamos is a significant theoretical and computational challenge and any window into interior dynamics greatly increases our understanding. Such a window is provided by exploring rapid dynamics, particularly MHD waves about the dynamo-defined basic state. This field is the subject of current attention as geophysical observations and numerical modellings advance. We here pay particular attention to torsional Alfvén waves/oscillations and magnetic Rossby waves, which may be regarded as typical axisymmetric and nonaxisymmetric modes, respectively, amongst a wide variety of wave classes of rapidly rotating MHD fluids. The excitation of those waves has been evidenced for the Earth - whilst their presence has also been suggested for Jupiter. We shall overview their dynamics, summarise our current understanding, and give open questions for future perspectives.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Patients' Experiences of Patient-Controlled Sedation: An Interview Study of Patients who Underwent Endoscopy

PURPOSE

Patient-controlled sedation (PCS) allows patients to self-administer sedative drugs during endoscopic retrograde cholangiopancreatography (ERCP). There is a paucity of research on the experiences of patients who used PCS. Therefore the purpose of this study was to describe the perioperative experiences of patients who used PCS during ERCP.

DESIGN

Prospective study using semi-structured interviews.

METHODS

Qualitative content analysis facilitated a latent understanding of the manifest content.

FINDINGS

Eleven interviews revealed three main themes and underlying categories that summarized the patient experience: participation (control and perioperative sedation); communication (personnel, information, safety, insecurity, and concern); and sensation (effects and side effects).

CONCLUSIONS

The participatory experience of PCS resulted not from the opportunity for patient involvement but, rather, the establishment of a patient-professional relationship. Specifically, the interactions between patients and health care professionals played a vital role in the patients' overall experience of PCS.

Why are they eco-friendly? Attributing eco-friendly descriptive norms to intrinsic motivation increases pro-environmental purchase intention

People perform pro-environmental behaviors not only out of intrinsic motivation, but also due to external factors such as expected social approval or financial gain. To the extent that people use their own motivations to infer the motivation of others, people may view descriptive norms favoring pro-environmental behavior as extrinsically motivated. This may in turn decrease the normative influence of the norm, as conformity can be negatively affected by perceptions that others are conforming mindlessly. While descriptive norms generally promote pro-environmental behavior change, the influential power of descriptive norms varies between studies. One possible explanation for these inconclusive findings is that people interpret others' behavior as either intrinsically- or extrinsically motivated. We propose that pro-environmental descriptive norms will be more influential when attributing others' pro-environmental behavior as intrinsically (e.g., pleasure of contributing to the environment) rather than extrinsically, motivated (e.g., fear of social disapproval). In two experiments (N = 1326), we compared participants' intention to purchase pro-environmental products between four conditions: control condition vs intrinsic norm vs extrinsic norm (Exp. 1) vs injunctive norm (Exp. 2). Results consistently found a significant increase in pro-environmental purchase intention in the intrinsic norm condition compared to both extrinsic norm condition (Exp. 2) and no-information control condition (Exp. 1 & 2). These studies highlight that attribution of behavior is vital for the adoption of pro-environmental norms.

Exploring Structural Uncertainty and Impact of Health State Utility Values on Lifetime Outcomes in Diabetes Economic Simulation Models: Findings from the Ninth Mount Hood Diabetes Quality-of-Life Challenge

BACKGROUND

Structural uncertainty can affect model-based economic simulation estimates and study conclusions. Unfortunately, unlike parameter uncertainty, relatively little is known about its magnitude of impact on life-years (LYs) and quality-adjusted life-years (QALYs) in modeling of diabetes. We leveraged the Mount Hood Diabetes Challenge Network, a biennial conference attended by international diabetes modeling groups, to assess structural uncertainty in simulating QALYs in type 2 diabetes simulation models.

METHODS

Eleven type 2 diabetes simulation modeling groups participated in the 9th Mount Hood Diabetes Challenge. Modeling groups simulated 5 diabetes-related intervention profiles using predefined baseline characteristics and a standard utility value set for diabetes-related complications. LYs and QALYs were reported. Simulations were repeated using lower and upper limits of the 95% confidence intervals of utility inputs. Changes in LYs and QALYs from tested interventions were compared across models. Additional analyses were conducted postchallenge to investigate drivers of cross-model differences.

RESULTS

Substantial cross-model variability in incremental LYs and QALYs was observed, particularly for HbA1c and body mass index (BMI) intervention profiles. For a 0.5%-point permanent HbA1c reduction, LY gains ranged from 0.050 to 0.750. For a 1-unit permanent BMI reduction, incremental QALYs varied from a small decrease in QALYs (-0.024) to an increase of 0.203. Changes in utility values of health states had a much smaller impact (to the hundredth of a decimal place) on incremental QALYs. Microsimulation models were found to generate a mean of 3.41 more LYs than cohort simulation models (P = 0.049).

CONCLUSIONS

Variations in utility values contribute to a lesser extent than uncertainty captured as structural uncertainty. These findings reinforce the importance of assessing structural uncertainty thoroughly because the choice of model (or models) can influence study results, which can serve as evidence for resource allocation decisions.HighlightsThe findings indicate substantial cross-model variability in QALY predictions for a standardized set of simulation scenarios and is considerably larger than within model variability to alternative health state utility values (e.g., lower and upper limits of the 95% confidence intervals of utility inputs).There is a need to understand and assess structural uncertainty, as the choice of model to inform resource allocation decisions can matter more than the choice of health state utility values.

Cost-Effectiveness of Once-Weekly Semaglutide 1 mg versus Canagliflozin 300 mg in Patients with Type 2 Diabetes Mellitus in a Canadian Setting

OBJECTIVE

Our objective was to evaluate the long-term cost-effectiveness of once-weekly semaglutide 1 mg versus once-daily canagliflozin 300 mg in patients with type 2 diabetes mellitus (T2DM) uncontrolled with metformin from the healthcare payer and societal perspectives in Canada.

METHODS

Head-to-head data from the SUSTAIN 8 randomised trial (NCT03136484) were extrapolated over 40 years using economic simulation modelling. The cost-effectiveness of once-weekly semaglutide 1 mg versus canagliflozin 300 mg for treating T2DM was estimated using the Swedish Institute for Health Economics-Diabetes Cohort Model (IHE-DCM) and the Economic and Health Outcomes Model of T2DM (ECHO-T2DM). Unit costs and disutility weights capturing treatments and key macro- and microvascular complications were sourced from the literature to best match the Canadian setting. A probabilistic base-case simulation and sensitivity analyses were conducted.

RESULTS

Once-weekly semaglutide 1 mg was associated with reductions in macro- and microvascular complications, yielding incremental cost-effectiveness ratios (ICERs) of (Canadian dollars [CAD]) CAD16,392 and 18,098 per incremental quality-adjusted life-year (QALY) gained versus canagliflozin 300 mg for IHE-DCM and ECHO-T2DM, respectively, from a healthcare payer perspective. Accounting for productivity loss as well, ICERs were CAD14,127 and 13,188 per QALY gained for IHE-DCM and ECHO-T2DM, respectively, from a societal perspective. Sensitivity analyses confirmed that the base-case results were robust to changes in input parameters and assumptions used.

CONCLUSIONS

At a willingness-to-pay threshold of CAD50,000 per QALY gained, once-weekly semaglutide 1 mg was cost-effective over 40 years versus once-daily canagliflozin 300 mg for the treatment of T2DM in patients failing to maintain glycemic control with metformin alone.

The public economic burden of suboptimal type 2 diabetes control upon taxpayers in Sweden: Looking beyond health costs

AIM

To estimate the fiscal burden for taxpayers in Sweden associated with type 2 diabetes (T2D) attributed to diabetes-related complications in patients failing to meet HbA1c targets.

MATERIAL AND METHODS

We developed a public economic framework to assess how changes in diabetes-related complications influenced projected tax contributions and government disability payments for people with T2D. The analysis applied accepted disease-modelling practices to estimate different rates of diabetes-related complications based on an HbA1c of 6.9% (52 mmol/mol) and of 6.0% (42 mmol/mol). We adjusted the employment activity rates for those experiencing T2D-related events, applying age-specific earnings to estimate lifetime tax losses. Furthermore, the likelihood of receiving payments for health-related employment inactivity was estimated. Direct healthcare costs are excluded from this analysis.

RESULTS

The estimated per person earnings loss for immediate and delayed HbA1c control was Swedish krona (SEK) 42 299 and SEK 44 157, respectively, over 10 years. The lost employment activity of people with T2D translates to lost tax revenues of SEK 23 265 and SEK 24 287 for immediate and delayed control, respectively. The estimated difference in disability payments was SEK 538. Combining the tax revenue loss and excess disability payments defines the broader fiscal costs, where we observe combined fiscal losses that favour immediate and sustained control by SEK 1560 over 10 years.

CONCLUSIONS

We show that conducting fiscal analysis of diabetes interventions offers an enriched perspective capturing a range of costs that fall on government in relation to lost tax revenue and disability payments. Tax-financed health systems may benefit from broadening the consideration of costs and benefits when evaluating new interventions and treatment practices.

Can unexpected support promote environmental policy acceptability? An experimental investigation of norm source and strength

Two experiments tested how environmental policy acceptability of US conservatives and liberals was influenced by manipulating the level (minority vs. majority) and source (in-group vs. outgroup) of normative support for policy. Results from 928 MechanicalTurk users (Study 1: N = 268, Study 2: N = 660) indicated that when evaluating an in-group policy (that participants expect their own political group to support), communicating outgroup support increases acceptability compared with communicating in-group support. The outgroup norm has a positive indirect effect via the inference that the in-group is even more supportive of the policy than the outgroup is. In contrast, when evaluating an outgroup policy, communicating in-group support indirectly yields higher acceptability than communicating outgroup support, via the inference that the outgroup is more supportive than the in-group is. This effect mainly occurred for individuals with strong ideological identification and was independent of level of support (minority vs. majority). Results indicate that bipartisan support for environmental policies can be achieved by strategic communication of normative information about political groups.

Long-Term Cost Effectiveness of Oral Semaglutide Versus Empagliflozin and Sitagliptin for the Treatment of Type 2 Diabetes in the Swedish Setting

OBJECTIVE

The aim of this study was to assess the cost effectiveness of oral semaglutide versus other oral glucose-lowering drugs for the management of type 2 diabetes (T2D) in Sweden.

METHODS

The Swedish Institute for Health Economics Diabetes Cohort Model was used to assess the cost effectiveness of oral semaglutide 14 mg versus empagliflozin 25 mg and oral semaglutide 14 mg versus sitagliptin 100 mg, using data from the head-to-head PIONEER 2 and 3 trials, respectively, in which these treatments were added to metformin (± sulphonylurea). Base-case and scenario analyses were conducted. Robustness was evaluated with deterministic and probabilistic sensitivity analyses.

RESULTS

In the base-case analyses, greater initial lowering of glycated haemoglobin levels with oral semaglutide versus empagliflozin and oral semaglutide versus sitagliptin, respectively, resulted in reduced incidences of micro- and macrovascular complications and was associated with lower costs of complications and indirect costs. Treatment costs were higher for oral semaglutide, resulting in higher total lifetime costs than with empagliflozin (Swedish Krona [SEK] 1,245,570 vs. 1,210,172) and sitagliptin (SEK1,405,789 vs. 1,377,381). Oral semaglutide was shown to be cost effective, with an incremental cost-effectiveness ratio (ICER) of SEK239,001 per quality-adjusted life-year (QALY) compared with empagliflozin and SEK120,848 per QALY compared with sitagliptin, from a payer perspective. ICERs were lower at SEK191,721 per QALY compared with empagliflozin and SEK95,234 per QALY compared with sitagliptin from a societal perspective. Results were similar in scenario analyses that incorporated cardiovascular effects, and also in sensitivity analyses.

CONCLUSIONS

In a Swedish setting, oral semaglutide was cost effective compared with empagliflozin and sitagliptin for patients with T2D inadequately controlled on oral glucose-lowering drugs.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02863328 (PIONEER 2; registered 11 August 2016) and NCT02607865 (PIONEER 3; registered 18 November 2015).

Consumption of Vegetables Is Associated with Systemic Inflammation in Older Adults

It is hypothesized that healthy diets rich in fruits and vegetables (FV) can modulate the inflammatory status in older adults. However, to determine the actual impact of FV on inflammatory status, adiposity level and objectively assessed physical activity (PA) behaviors need to be considered. The aim of the present study was to explore associations between FV intake and biomarkers of systemic inflammation in older adults. Based on a sample of 233 older adults (65−70 years old), the following inflammatory biomarkers were assessed: C-reactive protein (CRP), fibrinogen, interleukin-6 (IL-6), IL-10, IL-18, and monocyte chemoattractant protein-1 (MCP-1). FV intake was assessed by self-report, and PA behaviors encompassing time spent sedentary and in moderate-to-vigorous PA (MVPA) were determined using accelerometers. Associations between FV intake and inflammatory biomarkers were analyzed using stepwise linear regression models while adjusting for several covariates, including health-related food groups, adherence to the MVPA guidelines, total sedentary time, and waist circumference. While no significant associations were observed for the total FV intake, the vegetable intake was inversely associated with levels of IL6 (β = −0.15; p < 0.05). In contrast, fruit intake was not associated with any inflammatory biomarker. In conclusion, our findings indicate beneficial associations between vegetable intake and levels of a pro-inflammatory biomarker in older adults, which strengthens public health efforts to promote vegetable-rich diets in older adults to mitigate age-related systemic inflammation.

Effects of Reallocating Time Spent in Different Physical Activity Intensities on Sarcopenia Risk in Older Adults: An Isotemporal Substitution Analysis

Simple Summary

The role of daily time spent sedentary and in different intensities of physical activity (PA) for maintenance of muscle health is currently unclear. Therefore, we investigated the impact of reallocating time spent in different PA intensities on a sarcopenia risk score (SRS) in older adults, while considering PA type (muscle strengthening activities, MSA) and protein intake. In the present study, we show for the first time that reallocating sedentary time with at least light-intensity PA was significantly related to a lower SRS, which remained evident after adjustment by PA type (MSA) and protein intake. Similarly, reallocating time in light- to moderate-to-vigorous-intensity PA was related to a significantly lower SRS. Our results emphasize the importance of displacing sedentary behaviours for more active pursuits, where PA of even light intensities may alleviate age-related deteriorations of muscle health in older adults.

Abstract

The role of daily time spent sedentary and in different intensities of physical activity (PA) for the maintenance of muscle health currently remains unclear. Therefore, we investigated the impact of reallocating time spent in different PA intensities on sarcopenia risk in older adults, while considering PA type (muscle strengthening activities, MSA) and protein intake. In a sample of 235 community-dwelling older adults (65–70 years), a sarcopenia risk score (SRS) was created based on muscle mass assessed by bioimpedance, together with handgrip strength and performance on the five times sit-to-stand (5-STS) test assessed by standardized procedures. Time spent in light-intensity PA (LPA), moderate-to-vigorous PA (MVPA), and being sedentary was assessed by accelerometry, and PA type (MSA) by self-report. Linear regression models based on isotemporal substitution were employed. Reallocating sedentary time to at least LPA was significantly (p < 0.05) related to a lower SRS, which remained evident after adjustment by PA type (MSA) and protein intake. Similarly, reallocating time in LPA by MVPA was related to a significantly (p < 0.05) lower SRS. Our results emphasize the importance of displacing sedentary behaviours for more active pursuits, where PA of even light intensities may alleviate age-related deteriorations of muscle health in older adults.

Health economic modelling of diabetic kidney disease in patients with type 2 diabetes treated with Canagliflozin in Belgium

OBJECTIVES

The Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) trial showed reduced renal and cardiovascular (CV) events in patients with type 2 diabetes (T2D) and diabetic kidney disease (DKD) treated with canagliflozin 100 mg added to Standard of Care (SoC) versus SoC alone. This led to an extension of the canagliflozin 100 mg European marketing authorisation, making canagliflozin the first pharmacological therapy to receive authorisation for the treatment of DKD since the RENAAL and IDNT trials more than 20 years ago. Given the importance of cost-effectiveness analyses in health care, this study aimed to leverage the CREDENCE trial outcomes to estimate the cost-effectiveness of canagliflozin 100 mg from the perspective of the Belgian healthcare system.

METHODS

A microsimulation model (CREDENCE Economic Model of DKD), developed using patient-level CREDENCE trial data, was leveraged to model the progression of DKD and CV outcomes, associated costs, and life quality. Unit costs and quality-adjusted life years (QALYs) were sourced from the literature. The time horizon was 10 years and sensitivity analyses were performed.

RESULTS

Canagliflozin was associated with sizable gains in life-years and QALYs over 10 years, and the incremental cost-effectiveness ratio cost offsets associated with reductions in CV and renal complications resulted in overall net cost savings from the perspective of the Belgian healthcare system.

CONCLUSION

Model-based results suggest that adding canagliflozin 100 mg to SoC can improve outcomes for patients with DKD while reducing overall net costs for the Belgian healthcare system.

Randomized Controlled Trial for Promotion of Healthy Eating in Older Adults by Increasing Consumption of Plant-Based Foods: Effect on Inflammatory Biomarkers

To what extent the intake of fruit and vegetables (FV) influences inflammatory status remains elusive, particularly in older populations. The aim of the present study was to determine the effect of increased FV intake for 16 weeks on circulating biomarkers of inflammation in a population of older men and women. Sixty-six participants (65–70 years) randomly assigned to either FV or control (CON) groups were instructed to increase FV intake to five servings per day through nutritional counseling (FV) or to maintain habitual diet (CON). Dietary intake and physical activity level (PA) were determined using food frequency questionnaire and accelerometers, respectively, at the start and end of the intervention. C-reactive protein (CRP), interleukin 6 (IL-6), IL-18, macrophage inflammatory protein-1α (MIP-1α), MIP-1β, tumor necrosis factor-α (TNF-α), TNF-related apoptosis-inducing ligand (TRAIL), TNF-related activation-induced cytokine (TRANCE), and C-X3-C motif chemokine ligand-1 (CX3CL1, or fractalkine) were analyzed. The FV group significantly increased daily FV intake (from 2.2 ± 1.3 to 4.2 ± 1.8 servings/day), with no change in CON. Waist circumference and PA level were unchanged by the intervention. Interaction effects (time × group, p < 0.05) for TRAIL, TRANCE, and CX3CL1 denoting a significant decrease (p < 0.05) in FV but not in CON were observed. No corresponding effects on CRP, IL6, TNF-α, MIP-1α, and β and IL-18 were observed. The present study demonstrates the influence of increased FV consumption on levels of some inflammatory biomarkers in a population of older adults. Future work is warranted to examine the clinical implications of FV-induced alterations in these inflammatory biomarkers.

Healthy Eating Is Associated with Sarcopenia Risk in Physically Active Older Adults

Healthy Diet and physical activity may play important roles in the maintenance of muscle health during aging. The aim of the present study was to explore the impact of adherence to healthy dietary patterns on sarcopenia risk in a sample of physically active older men and women, while considering adherence to guidelines on muscle strengthening activities (MSA) and protein intake. Based on a sample of 191 physically active men and women (65-70 years), dietary intake was assessed using a 90-items food-frequency-questionnaire (FFQ) and Healthy Diet Score (HDS) was calculated. Physical activity was assessed by accelerometry and self-report. A sarcopenia risk score (SRS) was derived based on three indicators of muscle health: muscle mass was assessed using bioelectrical impedance and handgrip strength and 5 times sit-to-stand (5-STS) were determined by standardized procedures. Analysis of covariance (ANCOVA) was used to examine differences in SRS and its components across sex-specific tertiles of HDS, with adjustments for covariates including total energy intake, protein intake and MSA. A significant main effect (p < 0.05) of HDS on SRS was observed, where those belonging to the highest HDS tertile had lower SRS compared to those in the lowest tertile. A corresponding significant effect was observed for 5-STS performance, with better performance in those with the highest HDS adherence compared to those with the lowest. The present study supports guidelines emphasizing diet quality beyond amounts of macro- and micronutrients in the prevention of age-related deterioration of muscle health. Importantly, the benefits from healthy dietary patterns are evident in older adults who already adhere to guidelines for health-enhancing physical activity.

A Research Agenda to Better Understand the Human Dimensions of Energy Transitions

The Social Sciences and Humanities (SSH) have a key role to play in understanding which factors and policies would motivate, encourage and enable different actors to adopt a wide range of sustainable energy behaviours and support the required system changes and policies. The SSH can provide critical insights into how consumers could be empowered to consistently engage in sustainable energy behaviour, support and adopt new technologies, and support policies and changes in energy systems. Furthermore, they can increase our understanding of how organisations such as private and public institutions, and groups and associations of people can play a key role in the sustainable energy transition. We identify key questions to be addressed that have been identified by the Platform for Energy Research in the Socio-economic Nexus (PERSON, see person.eu), including SSH scholars who have been studying energy issues for many years. We identify three main research themes. The first research theme involves understanding which factors encourage different actors to engage in sustainable energy behaviour. The second research theme focuses on understanding which interventions can be effective in encouraging sustainable energy behaviour of different actors, and which factors enhance their effects. The third research theme concerns understanding which factors affect public and policy support for energy policy and changes in energy systems, and how important public concerns can best be addressed as to reduce or prevent resistance.

Macrovascular Risk Equations Based on the CANVAS Program

BACKGROUND

Widely used risk equations for cardiovascular outcomes for individuals with type 2 diabetes mellitus (T2DM) have been incapable of predicting cardioprotective effects observed in recent cardiovascular outcomes trials (CVOTs) involving individuals with T2DM at high risk for or with established cardiovascular disease (CVD).

OBJECTIVE

We developed cardiovascular and mortality risk equations using patient-level data from the CANVAS (CANagliflozin cardioVascular Assessment Study) Program to address this shortcoming.

METHODS

Data from 10,142 patients with T2DM at high risk for or with established CVD, randomized to canagliflozin + standard of care (SoC) or SoC alone and followed for a mean duration of 3.6 years in the CANVAS Program were used to derive parametric risk equations for myocardial infarction (MI), stroke, hospitalization for heart failure (HHF), and death. Accumulated knowledge from the widely used UKPDS-OM2 (United Kingdom Prospective Diabetes Study Outcomes Model 2) was leveraged, and any departures in parameterization were limited to those necessary to provide adequate goodness of fit. Candidate explanatory covariates were selected using only the placebo arm to minimize confounding effects. Internal validation was performed separately by study treatment arm.

RESULTS

UKPDS-OM2 predicted CANVAS Program outcomes poorly. Recalibrating UKPDS-OM2 intercepts improved calibration in some cases. Refitting the coefficients but otherwise preserving the UKPDS-OM2 structure improved the fit substantially, which was sufficient for stroke and death. For MI, reselecting UKPDS-OM2 covariates and functional form proved sufficient. For HHF, selection from a broad set of candidate covariates and inclusion of a canagliflozin indicator was required.

CONCLUSION

These risk equations address some of the limitations of widely used risk equations, such as the UKPDS-OM2, for modeling cardioprotective treatments for individuals with T2DM and high cardiovascular risk, including derivation from overly healthy patients treated with agents that lack cardioprotection and have been described as reflecting a different therapeutic era. Future work is needed to examine external validity.

Sedentary Patterns and Systemic Inflammation: Sex-Specific Links in Older Adults

The study aimed to examine sex-specific associations between objectively measured sedentary patterns and pro- and anti-inflammatory biomarkers in older adults when considering the moderating impact of physical activity (PA). Accelerometer-based monitoring of sedentary patterns and PA was conducted in a population of older men (n = 83; age: 67.4 ± 1.5; height: 178.7 ± 6.6 cm; weight: 80.9 ± 10.6 kg) and women (n = 146; age: 67.4 ± 1.6; height: 164.2 ± 6.1 cm; weight: 64.6 ± 10.1 kg) aged 65-70. Blood samples were collected for the assessment of the inflammatory biomarkers C-reactive protein (CRP), fibrinogen, interleukin-6 (IL-6), IL-10, IL-18, and monocyte chemoattractant protein-1 (MCP-1). Data were analyzed using multiple linear regression models. Total and bouts of ≥10 min of sedentary time were inversely associated with the anti-inflammatory marker IL-10 in older men (accumulated sedentary time: β = -0.116; bouts: β = -0.099; all p < 0.05). Associations were independent of moderate-to-vigorous physical activity (MVPA) and total PA volume. In women, total and bouts of ≥10 min of sedentary time were detrimentally associated with the pro-inflammatory marker fibrinogen (accumulated sedentary time: β = -0.130; bouts: β = -0.085; all p < 0.05). Associations remained between accumulated sedentary time and fibrinogen when adjusting for MVPA and total PA volume. This study highlights sex-specific routes by which sedentary patterns impact on pro- and anti-inflammatory biomarkers in older adults. The findings support efforts to promote accumulation of time spent in PA at the expense of time in sedentary pursuits on low-grade inflammation in older men and women.

Muscle mass and aerobic capacity in older women: Impact of regular exercise at middle age

BACKGROUND

The impact of regular exercise habits at middle-age on muscle mass and function at old age remains inconclusive. While regular exercise likely represents a primary source of health-enhancing physical activity (PA), the physical demand of occupation needs to be considered. Additionally, PA level at old age should be taken into account in order to elucidate true associations between past exercise behaviors and muscle mass and function at old age. Therefore, the aim of the study was to examine the impact of regular exercise habits during middle age years on muscle mass and physical function at old age, while considering occupation and objectively assessed PA level at old age.

METHODS

Self-reported leisure-time PA during middle age years [35-65 years] and present accelerometer-derived PA level were assessed in a population of community-dwelling older women (65-70 years; n = 112). Participants who accumulated at least 600 MET-min of PA per week during middle age years were classified as physically active. Skeletal muscle mass index (SMI), aerobic fitness and maximal isometric arm and leg strength were determined. Analyses of differences in muscle mass and physical function between physically active and inactive at middle age were adjusted by present PA, adiposity level, and the physical demand of former occupation (sedentary vs manual).

RESULTS

Participants accumulating at least 600 MET-min of exercise-related activities during middle-age years had higher aerobic fitness (P < 0.01) and SMI (P < 0.05) at old age compared to their less active peers. Notably, these beneficial impacts were driven by exercise habits during late middle-age period [50 to 65 years], and remained significant after further adjustment by the physical demand of former occupation and present PA behavior at old age. Finally, middle-age engagement in exercise-related activities had no influence on maximal arm and leg isometric strength at old age.

CONCLUSION

Our findings highlight the importance of engaging in regular PA of at least moderate intensity during middle age years in order to promote benefits at the level of muscle mass and aerobic fitness. This clearly supports the potential of PA in delaying aerobic capacity impairment and the occurrence of clinically manifest sarcopenia at old age.

Engagement in Muscle-Strengthening Activities Lowers Sarcopenia Risk in Older Adults Already Adhering to the Aerobic Physical Activity Guidelines

Sarcopenia in older adults is associated with a higher risk of falls, disability, loss of independence, and mortality. Current physical activity (PA) guidelines recommend engagement in muscle-strengthening activities (MSA) in addition to aerobic moderate-to-vigorous physical activity (MVPA). However, little is known about the impact of MSA in addition to adherence to the MVPA recommendation in the guidelines. The aim of the present cross-sectional study was to determine whether or not engagement in MSA is linked to sarcopenia risk in older adults who meet the PA guidelines of 150 min of MVPA per week. A total of 193 community-dwelling older men and women (65–70 years) were included in the study. A continuous sex-specific clustered sarcopenia risk score (SRS) was created based on muscle mass assessed using bioelectrical impedance analysis, handgrip strength, and five times sit-to-stand (5STS) time, assessed using standardized procedures. Adherence to PA guidelines was assessed using the Actigraph GT3x accelerometer and the EPAQ2 questionnaire. Guideline adherence to MSA twice a week was related to a significantly (p < 0.05) lower SRS compared to those who did not. This finding was evident after adjustment for adherence to the protein intake guideline and abdominal obesity. Similar impacts were observed for muscle mass and 5-STS but not for handgrip strength. In conclusion, guideline adherence to MSA is related to lower sarcopenia risk in older adults who already accumulate 150 weekly minutes of MVPA, which reinforces the promotion of the MSA guideline, alongside the MVPA guideline, to fight against sarcopenia progression in ageing populations.

Cost-Effectiveness of Canagliflozin Added to Standard of Care for Treating Diabetic Kidney Disease (DKD) in Patients with Type 2 Diabetes Mellitus (T2DM) in England: Estimates Using the CREDEM-DKD Model

INTRODUCTION

On the basis of reductions in diabetic kidney disease (DKD) progression and major adverse cardiovascular events observed in the landmark CREDENCE trial, canagliflozin 100 mg received an extension to its EU marketing authorisation in July 2020 to include the treatment of DKD in people with type 2 diabetes mellitus (T2DM) making it the first pharmacological therapy to receive regulatory authorisation for treatment of DKD since the RENAAL and IDNT trials in nearly 20 years. Efficient allocation of limited healthcare resources requires evaluation not only of clinical safety and efficacy but also economic consequences. The study aim was to estimate the cost-effectiveness of canagliflozin when added to current standard of care (SoC) versus SoC alone from the perspective of the NHS in England.

METHODS

A microsimulation model was developed using patient-level data from CREDENCE, including risk equations for the key clinical outcomes of start of dialysis, hospitalisation for heart failure, nonfatal myocardial infarction, nonfatal stroke, and all-cause mortality. DKD progression was modelled using estimated glomerular filtration rate and urinary albumin-to-creatinine ratio evolution equations. Risk for kidney transplant was sourced from UK-specific sources given the near absence of events in CREDENCE. Patient characteristics and treatment effects were sourced from CREDENCE. Unit costs (£2019) and disutility weights were sourced from the literature and discounted at 3.5% annually. The time horizon was 10 years in the base case, and sensitivity analysis was performed.

RESULTS

Canagliflozin was associated with sizable gains in life-years and quality-adjusted life-year (QALYs) over 10 years, with gains increasing with simulation duration. Cost offsets associated with reductions in cardiovascular and renal complications were sufficient to achieve overall net cost savings. The findings were generally confirmed in the sensitivity analyses.

CONCLUSION

Model results suggest that adding canagliflozin 100 mg to SoC can improve patient outcomes while reducing overall net costs from the NHS perspective in England.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02065791.

Fighting Sarcopenia in Ageing European Adults: The Importance of the Amount and Source of Dietary Proteins

While an adequate protein intake is important for the maintenance of muscle mass during ageing, the amount and source of protein necessary for optimal prevention of sarcopenia remains to be determined. The present study aimed to investigate the influence of the amount and source of dietary proteins on sarcopenia risk in a cohort of 65–79-year-old European adults within the frame of the NU-AGE study. A total of 986 participants were included in the analysis. Skeletal muscle index (SMI), assessed by dual-energy X-ray absorptiometry (DXA), and handgrip strength (HG) were employed to create a continuous sex-specific sarcopenia risk score (SRS). Total amount together with animal- and plant-derived sources of proteins were obtained from a 7-day food record. Differences in SRS were analysed across groups of total protein intake (<0.8 g/body weight (BW); 0.8–<1.0 g/BW; 1.0–<1.2 g/BW; and ≥1.2 g/BW). The association between SRS and the different sources of protein was assessed using isocaloric substitution models adjusted by demographic, medical, and lifestyle factors. A significant linear dose-response relationship was observed, with a lower SRS linked to higher protein intakes. Based on the isocaloric substitution modelling, a reduced SRS was observed when increasing plant protein to the detriment of animal protein, while holding total protein intake constant. Further, this result remained significant after stratifying the analysis by adherence to different levels of protein intake. Our findings suggest that older adults may benefit from increasing protein intakes above current recommendations. Besides total amount, protein source should be considered when promoting health dietary habits in older adults for the prevention of sarcopenia.

Development and Internal Validation of a Discrete Event Simulation Model of Diabetic Kidney Disease Using CREDENCE Trial Data

INTRODUCTION

The Canagliflozin and Renal Endpoints in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) study showed that compared with placebo, canagliflozin 100 mg significantly reduced the risk of major cardiovascular events and adverse renal outcomes in patients with diabetic kidney disease (DKD). We developed a simulation model that can be used to estimate the long-term health and economic consequences of DKD treatment interventions for patients matching the CREDENCE study population.

METHODS

The CREDENCE Economic Model of DKD (CREDEM-DKD) was developed using patient-level data from CREDENCE (which recruited patients with estimated glomerular filtration rate 30 to < 90 mL/min/1.73 m², urinary albumin to creatinine ratio > 300-5000 mg/g, and taking the maximum tolerated dose of a renin-angiotensin-aldosterone system inhibitor). Risk prediction equations were fit for start of maintenance dialysis, doubling of serum creatinine, hospitalization for heart failure, nonfatal myocardial infarction, nonfatal stroke, and all-cause mortality. A micro-simulation model was constructed using these risk equations combined with user-definable kidney transplant event risks. Internal validation was performed by loading the model to replicate the CREDENCE study and comparing predictions with trial Kaplan-Meier estimate curves. External validation was performed by loading the model to replicate a subgroup of the CANagliflozin cardioVascular Assessment Study (CANVAS) Program with patient characteristics that would have qualified for inclusion in CREDENCE.

RESULTS

Risk prediction equations generally fit well and exhibited good concordance, especially for the placebo arm. In the canagliflozin arm, modest underprediction was observed for myocardial infarction, along with overprediction of dialysis, doubling of serum creatinine, and all-cause mortality. Discrimination was strong (0.85) for the renal outcomes, but weaker for the macrovascular outcomes and all-cause mortality (0.60-0.68). The model performed well in internal and external validation exercises.

CONCLUSION

CREDEM-DKD is an important new tool in the evaluation of treatment interventions in the DKD population.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02065791.

Beneficial Role of Replacing Dietary Saturated Fatty Acids with Polyunsaturated Fatty Acids in the Prevention of Sarcopenia: Findings from the NU-AGE Cohort

Dietary fat subtypes may play an important role in the regulation of muscle mass and function during ageing. The aim of the present study was to determine the impact of isocaloric macronutrient substitutions, including different fat subtypes, on sarcopenia risk in older men and women, while accounting for physical activity (PA) and metabolic risk. A total of 986 participants, aged 65–79 years, completed a 7-day food record and wore an accelerometer for a week. A continuous sex-specific sarcopenia risk score (SRS), including skeletal muscle mass assessed by dual-energy X-ray absorptiometry (DXA) and handgrip strength, was derived. The impact of the isocaloric replacement of saturated fatty acids (SFAs) by either mono- (MUFAs) or poly-unsaturated (PUFAs) fatty acids on SRS was determined using regression analysis based on the whole sample and stratified by adherence to a recommended protein intake (1.1 g/BW). Isocaloric reduction of SFAs for the benefit of PUFAs was associated with a lower SRS in the whole population, and in those with a protein intake below 1.1 g/BW, after accounting for age, smoking habits, metabolic disturbances, and adherence to PA guidelines. The present study highlighted the potential of promoting healthy diets with optimised fat subtype distribution in the prevention of sarcopenia in older adults.

Evaluating the Ability of Economic Models of Diabetes to Simulate New Cardiovascular Outcomes Trials: A Report on the Ninth Mount Hood Diabetes Challenge

OBJECTIVES

The cardiovascular outcomes challenge examined the predictive accuracy of 10 diabetes models in estimating hard outcomes in 2 recent cardiovascular outcomes trials (CVOTs) and whether recalibration can be used to improve replication.

METHODS

Participating groups were asked to reproduce the results of the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME) and the Canagliflozin Cardiovascular Assessment Study (CANVAS) Program. Calibration was performed and additional analyses assessed model ability to replicate absolute event rates, hazard ratios (HRs), and the generalizability of calibration across CVOTs within a drug class.

RESULTS

Ten groups submitted results. Models underestimated treatment effects (ie, HRs) using uncalibrated models for both trials. Calibration to the placebo arm of EMPA-REG OUTCOME greatly improved the prediction of event rates in the placebo, but less so in the active comparator arm. Calibrating to both arms of EMPA-REG OUTCOME individually enabled replication of the observed outcomes. Using EMPA-REG OUTCOME-calibrated models to predict CANVAS Program outcomes was an improvement over uncalibrated models but failed to capture treatment effects adequately. Applying canagliflozin HRs directly provided the best fit.

CONCLUSIONS

The Ninth Mount Hood Diabetes Challenge demonstrated that commonly used risk equations were generally unable to capture recent CVOT treatment effects but that calibration of the risk equations can improve predictive accuracy. Although calibration serves as a practical approach to improve predictive accuracy for CVOT outcomes, it does not extrapolate generally to other settings, time horizons, and comparators. New methods and/or new risk equations for capturing these CV benefits are needed.

Comparing the Cohort and Micro-Simulation Modeling Approaches in Cost-Effectiveness Modeling of Type 2 Diabetes Mellitus: A Case Study of the IHE Diabetes Cohort Model and the Economics and Health Outcomes Model of T2DM

BACKGROUND

Economic modeling is widely used in estimating cost-effectiveness in type 2 diabetes mellitus. Because type 2 diabetes is complex and patients are heterogenous, the cohort modeling approach may generate biased estimates of costeffectiveness. The IHE Diabetes Cohort Model (IHE-DCM) was constructed using the cohort approach as an alternative for stakeholders with limited resources, some of whom have voiced reasonable concerns about a lack of transparency with type 2 diabetes micro-simulation models and long run times.

OBJECTIVES

The objective of this study was to inform decision makers by investigating the direction and magnitude of bias of IHE-DCM cost-effectiveness estimates that can be attributed to the cohort modeling approach.

METHODS

Simulation scenarios inspired by the 9th Mount Hood Diabetes Challenge were simulated with IHE-DCM and with a micro-simulation model, the Economic and Health Outcomes Model of T2DM (ECHO-T2DM), and key metrics (absolute and incremental costs and quality-adjusted life-years, event rates, and cost-effectiveness) were compared for evidence of systematic differences. The models were harmonized to the extent possible to ensure that differences were driven primarily by the unit of observation and not by other model differences.

RESULTS

IHE-DCM run times were faster and IHE-DCM produced uniformly larger estimates of absolute life-years, quality-adjusted life-years, and costs than ECHO-T2DM but smaller between-arm (incremental) differences. Estimated incremental cost-effectiveness ratios and net monetary benefits varied similarly and predictably across the scenarios. On average, IHE-DCM estimates of incremental cost-effectiveness ratios and net monetary benefits were CAN$269 (3%) and CAN$2935 (10%) smaller, respectively, than ECHO-T2DM.

CONCLUSIONS

There was little evidence that estimated cost-effectiveness metrics, the outcomes that matter most to stakeholders, differed systematically.

On the preconditions for large-scale collective action

The phenomenon of collective action and the origin of collective action problems have been extensively and systematically studied in the social sciences. Yet, while we have substantial knowledge about the factors promoting collective action at the local level, we know far less about how these insights travel to large-scale collective action problems. Such problems, however, are at the heart of humanity's most pressing challenges, including climate change, large-scale natural resource depletion, biodiversity loss, nuclear proliferation, antibiotic resistance due to overconsumption of antibiotics, and pollution. In this paper, we suggest an analytical framework that captures the theoretical understanding of preconditions for large-scale collective action. This analytical framework aims at supporting future empirical analyses of how to cope with and overcome larger-scale collective action problems. More specifically, we (i) define and describe the main characteristics of a large-scale collective action problem and (ii) explain why voluntary and, in particular, spontaneous large-scale collective action among individual actors becomes more improbable as the collective action problem becomes larger, thus demanding interventions by an external authority (a third party) for such action to be generated. Based on this, we (iii) outline an analytical framework that illustrates the connection between third-party interventions and large-scale collective action. We conclude by suggesting avenues for future research.

Dietary Fibre May Mitigate Sarcopenia Risk: Findings from the NU-AGE Cohort of Older European Adults

Sarcopenia is characterised by a progressive loss of skeletal muscle mass and physical function as well as related metabolic disturbances. While fibre-rich diets can influence metabolic health outcomes, the impact on skeletal muscle mass and function is yet to be determined, and the moderating effects by physical activity (PA) need to be considered. The aim of the present study was to examine links between fibre intake, skeletal muscle mass and physical function in a cohort of older adults from the NU-AGE study. In 981 older adults (71 ± 4 years, 58% female), physical function was assessed using the short-physical performance battery test and handgrip strength. Skeletal muscle mass index (SMI) was derived using dual-energy X-ray absorptiometry (DXA). Dietary fibre intake (FI) was assessed by 7-day food record and PA was objectively determined by accelerometery. General linear models accounting for covariates including PA level, protein intake and metabolic syndrome (MetS) were used. Women above the median FI had significantly higher SMI compared to those below, which remained in fully adjusted models (24.7 ± 0.2% vs. 24.2 ± 0.1%, p = 0.011, η²p = 0.012). In men, the same association was only evident in those without MetS (above median FI: 32.4 ± 0.3% vs. below median FI: 31.3 ± 0.3%, p = 0.005, η²p = 0.035). There was no significant impact of FI on physical function outcomes. The findings from this study suggest a beneficial impact of FI on skeletal muscle mass in older adults. Importantly, this impact is independent of adherence to guidelines for protein intake and PA, which further strengthens the potential role of dietary fibre in preventing sarcopenia. Further experimental work is warranted in order to elucidate the mechanisms underpinning the action of dietary fibre on the regulation of muscle mass.

Impact of healthy diet and physical activity on metabolic health in men and women: Study Protocol Clinical Trial (SPIRIT Compliant)

INTRODUCTION

Healthy dietary patterns and physical activity (PA) represent important lifestyle behaviors with considerable potential to influence on age-related metabolic health. Yet, data on the combined effects of these lifestyle behaviors on metabolic health including low-grade systemic inflammation in aging populations remain scarce. Therefore, this protocol describes a randomized controlled trial aiming to examine the impacts of healthy dietary patterns alone or combined with PA on metabolic health in middle-aged and older men and women.

MATERIAL AND METHODS

The ORUDIET study is a 3-arm randomized controlled 16-week trial: Healthy Diet (HD), Healthy diet plus PA (HD-PA), and control (CON). The trial is open label, randomized with allocation concealment, parallel groups with passive controls. Participants without overt disease aged between 55 and 70 years, with BMI below 35, a current intake of a maximum of 1 serving of fruit and vegetable per day, and noncompliance to PA guidelines are eligible for inclusion. Participants in HD are instructed to increase fruit and vegetable intake to 5 servings per day (equivalent to 500 g). Participants in HD-PA receive the same dietary intervention as the HD and are additionally instructed to engage in moderate-to-vigorous physical activities for at least 150 minutes per week. The primary study outcomes are changes in metabolic and inflammatory health biomarkers. Secondary outcomes are changes in body composition and perceived health.

ETHICS AND DISSEMINATION

The study protocol has been approved by the ethical review board in Uppsala, Sweden. The results will be published in peer-reviewed journals and disseminated in national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04062682 Pre-results.

Patient-controlled sedation with propofol for endoscopic procedures-A cost analysis

BACKGROUND

Patient-controlled sedation (PCS) with propofol accompanied by a bedside nurse anaesthetist is an alternative sedation method for endoscopic procedures compared with midazolam administered by a nurse or endoscopist. Increasing costs in health care demands an economic perspective when introducing alternative methods. We applied a hospital perspective on a cost analysis comparing different methods of sedation and the resource use that were expected to affect cost differences related to the sedation.

METHODS

Based on two randomised previous studies, the direct costs were determined for different sedation methods during two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and flexible bronchoscopy including endobronchial ultrasound. ERCP comparisons were made between midazolam sedation by the endoscopic team, PCS with a bedside nurse anaesthetist and propofol sedation administered by a nurse anaesthetist. Bronchoscopy comparisons were made between midazolam sedation by the endoscopic team and PCS with a bedside nurse anaesthetist, categorised by premedication morphine-scopolamine or glycopyrronium.

RESULTS

Propofol PCS with a bedside nurse anaesthetist resulted in lower costs per patient for sedation for both ERCP (233 USD) and bronchoscopy (premedication morphine-scopolamine 267 USD, premedication glycopyrronium 269 USD) compared with midazolam (ERCP 425 USD, bronchoscopy 337 USD). Aborted procedures that needed to be repeated and prolonged hospital stays significantly increased the cost for the midazolam groups.

CONCLUSION

Propofol PCS with a bedside nurse anaesthetist reduces the direct sedation costs for ERCP and bronchoscopy procedures compared with midazolam sedation.

Challenges and Opportunities Associated with Incorporating New Evidence of Drug-Mediated Cardioprotection in the Economic Modeling of Type 2 Diabetes: A Literature Review

INTRODUCTION

Cardiovascular disease is a leading cause of mortality in people with type 2 diabetes mellitus (T2DM). Beginning in 2015, long-term cardiovascular outcomes trials (CVOTs) have reported cardioprotective benefits for two classes of diabetes drugs. In addition to improving the lives of patients, these health benefits affect relative value (i.e., cost-effectiveness) of these agents compared with each other and especially compared with other agents. While long-term CVOT data on hard outcomes are a great asset, economic modeling of the value of this cardioprotection faces many new empirical challenges. The aim of this study was to identify different approaches used to incorporate drug-mediated cardioprotection into T2DM economic models, to identify pros and cons of these approaches, and to highlight additional considerations.

METHODS

A review of T2DM modeling applications (manuscript or conference abstracts) that included direct cardioprotective effects was conducted from January 2015 to September 2018. Model applications were classified on the basis of the mechanism used to model cardioprotection [i.e., directly via hazard ratios (HRs) for cardiovascular outcomes or indirectly via biomarker mediation]. Details were extracted and the studies were evaluated.

RESULTS

Five full-length articles and 16 conference abstracts (of which 11 posters were found) qualified for study inclusion. While the approaches used were diverse, the five full-length publications and all but two of the abstracts modeled cardioprotection used direct HRs from the relevant CVOT. The remaining two posters modeled cardioprotection using CVOT HRs in combination with treatment effects mediated through known risk factors.

CONCLUSION

The classification of empirical methods in cardioprotection was intended to facilitate a better understanding of the pros and cons of different methodologies. A substantial diversity was observed, though most used trial HRs directly. Given the differences observed, we believe that diabetes modelers and other stakeholders can benefit from a formal discussion and evolving consensus.

FUNDING

Janssen Global Services, LLC (Raritan, NJ, USA).

Anxiety and depression after burn, not as bad as we think-A nationwide study

OBJECTIVE

A history of psychiatric disorders is more common among patients who have had burns than in the general population. To try and find out the scale of the problem we have assessed self-reported symptoms of anxiety and depression after a burn.

METHODS

Consecutive patients with burns measuring more than 10% total body surface area or duration of stay in hospital of seven days or more were included. Personal and clinical details about the patients were extracted from the database at each center. Data were collected from the Hospital Anxiety and Depression Scale, as well as Health-Related Quality of Life (HRQoL; Short Form-36, SF-36) and questionnaires about socioeconomic factors. All results were obtained 12 and 24 months after the burn, and compared with those from a reference group.

RESULTS

A total of 156 patients responded to the questionnaires. Mean (SD) age and TBSA (%) were 46 (16.4) years and 23.6 (19.2) %, respectively. There were no differences in incidence between the burn and reference groups in anxiety or depression either 12 or 24 months after the burn. Those who reported higher anxiety and depression scores also had consistently poorer HRQoL as assessed by the SF-36.

CONCLUSION

Seen as a group, people who have had burns report anxiety and depression the same range as a reference group. Some patients, however, express more anxiety and depression, and concomitantly poorer HRQoL. These patients should be identified, and offered additional support.

Cardiorespiratory Fitness Does Not Offset Adiposity-Related Systemic Inflammation in Physically Active Older Women

CONTEXT

Chronic inflammation increases diabetes risk and may be exacerbated by excess adipose tissue. Whether cardiovascular fitness can offset chronic inflammation associated with excess adipose tissue in older adults is unclear.

OBJECTIVE

The study aimed to examine the influence of cardiorespiratory fitness on links between adiposity and pro- and anti-inflammatory biomarkers related to metabolic risk in physically active older women.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional study comprising older community-dwelling women (n = 109; age, 65-70 yr).

MAIN OUTCOME

Cardiorespiratory fitness was assessed using a standardized submaximal test and participants were categorized into high and low adiposity-related metabolic risk (body mass index, waist-to-hip ratio (WHR) and total fat mass). The inflammatory biomarkers C-reactive protein (CRP), interleukin-6 (IL-6), IL-10, IL-18, adiponectin, monocyte chemoattractant protein-1 (MCP-1), and macrophage inflammatory protein (MIP-1α) were analyzed.

RESULTS

Regardless of adiposity measure, women in the metabolic high-risk group had significantly (P<0.05) elevated CRP and lower adiponectin levels. Levels of IL-6 and MIP1-α were significantly elevated in the high-risk group defined by WHR and total fat mass. IL-18 level was significantly elevated in the high-risk group based on WHR only. Importantly, a high cardiorespiratory fitness level did not attenuate the detrimental links between adiposity measures and inflammation.

CONCLUSIONS

Altogether, cardiorespiratory fitness does not offset the detrimental links between adiposity and several inflammatory biomarkers related to metabolic risk in physically active older women. Reducing abdominal adipose tissue in older adults should be emphasized in efforts aiming to attenuate age-related systemic inflammation and metabolic risk regardless of cardiorespiratory fitness.

Adherence to DASH-Style Dietary Pattern Impacts on Adiponectin and Clustered Metabolic Risk in Older Women

While dietary patterns are related to the age-related progression of chronic diseases, to what extent different dietary patterns influence inflammatory and metabolic risk factors in older adults remains to be elucidated. Additionally, potential moderating effects by physical activity (PA) become important to clarify. Here, we hypothesize that dietary patterns are linked to inflammatory and metabolic biomarkers and that these links are independent of PA. The present study aims to explore links between two dietary constructs and biomarkers of systemic inflammation and metabolic health in older women, while considering time spent in moderate-to-vigorous PA (MVPA). A cross-sectional analysis of a sample of 112 community-dwelling older women (65–70 years old) was performed. Dietary constructs based on the Dietary Approach to Stop Hypertension (DASH) and the dietary inflammatory index (DII) were determined from food records. MVPA was objectively assessed using accelerometry. Metabolic outcomes (waist circumference, systolic/diastolic blood pressures and levels of glucose, triglycerides and high-density lipoprotein (HDL)-cholesterol) and inflammatory biomarkers (C-reactive protein (CRP), fibrinogen and adiponectin) were determined using standardized procedures and a clustered metabolic risk score was derived. Adherence to DASH-style diet was significantly (p < 0.05) associated with a lower clustered metabolic risk, where women in the highest adherence group had a significantly (p < 0.05) lower waist circumference and blood glucose level compared to those in the lowest group. Further, a significantly higher (p < 0.05) adiponectin level was observed in the high DASH adherence group compared to those with low adherence. Notably, adjustment by waist circumference did not alter links with either adiponectin or blood glucose level. Importantly, all observed links remained significant after further adjustment for time in MVPA. Finally, no significant associations were observed when the dietary pattern was defined by the DII. The findings of this study demonstrate that DASH-style diets promote a systemic anti-inflammatory environment, while also mitigating clustered metabolic risk in older women. A key finding is that favourable impacts of the DASH-style diet are independent of time spent in moderate-to-vigorous PA, which further strengthens healthy eating behaviours as a key target for clinical and public health interventions designed to prevent age-related metabolic abnormalities.

Physical Activity Alters Inflammation in Older Adults by Different Intensity Levels

PURPOSE

To examine the influence of reallocating time spent at different objectively measured physical activity (PA) behaviors on markers of systemic inflammation in older women with different levels of metabolic risk.

METHODS

Accelerometer-based monitoring of PA was conducted in a population of community-dwelling older women (n = 111; age, 65-70 yr) for determination of daily sedentary time, time in light PA (LPA) and moderate-to-vigorous PA (MVPA). Blood samples were collected for the assessment of the systemic inflammatory markers C-reactive protein (CRP), fibrinogen, and adiponectin. Metabolic risk was assessed by standardized procedures based on definitions for the metabolic syndrome. Data were analyzed by linear regression models based on isotemporal substitution analysis.

RESULTS

Reallocating 30 min of sedentary time with either time in LPA (β = -0.47; P < 0.05) or MVPA (β = -0.42; P < 0.05) was related to reduced fibrinogen level, whereas no corresponding effect was evident when shifting time in LPA with time in MVPA, while holding sedentary time constant. In contrast, reallocating a 30-min period in sedentary (β = -0.70; P < 0.01) or LPA (β = -0.71; P < 0.01) with MVPA was associated with a significant reduction in CRP level, whereas no impact on CRP was observed when a period of sedentary behavior was replaced with LPA. Importantly, all significant influences on fibrinogen and CRP by displacement of different PA behaviors remained after adjustment for metabolic risk status among participants. No significant associations with adiponectin were observed.

CONCLUSIONS

Altogether, this work supports the existence of different intensity thresholds mediating beneficial effects of PA on important clinical markers of systemic inflammation in older women across different stages of disease prevention.

Experiencing a Severe Weather Event Increases Concern About Climate Change

Climate change is primarily driven by human-caused greenhouse gas (GHG) emissions, and may therefore be mitigated by changes to human behavior (Clayton et al., 2015; IPCC, 2018). Despite efforts to raise awareness and concern about climate change, GHG emissions continue to rise (IPCC, 2018). Climate change seems to be at odds with the immediate, present threats to which humans are adapted to cope (Gifford et al., 2009; Schultz, 2014; van Vugt et al., 2014). In contrast to immediate dangers, climate change is typically abstract, large scale, slow and often unrelated to the welfare of our daily lives (e.g., Ornstein and Ehrlich, 1989; Gifford, 2011). But there are moments when the consequences of climate change are readily apparent, such as extreme weather events. In the current paper, we examine the impact of personal experience with an extreme weather event, and the impact of this experience on beliefs about climate change, and intentions to take actions that can help prepare for and mitigate the consequences of climate change.

Good-bye slippage - a new fusion to tackle bandage slippage on the foot

Not available

A call to greater inclusion of gerodontology in the dental curriculum: A narrative review

AIM

This literature review explores the need for greater prominence of gerodontology in the undergraduate dental curriculum, focusing on the significance of gerodontology for dental students on clinical placements.

BACKGROUND

As Australia's population ages the number of dentate older people is increasing. An assessment of the dental profession's preparedness, including that of future providers, is needed to ensure that this public health issue is addressed.

METHODS

A database search was performed in MEDLINE (Ovid), CINAHL and JCU OneSearch. Of the 41 articles identified, 31 were selected for review using a narrative approach.

DISCUSSION

Of the 31 articles reviewed, 12 were Australian, 9 North American and 5 European. Five overarching themes were identified, including preparedness for residential aged care facilities; barriers to oral health services provision; attitudes to aged care; gerodontology as part of a dental school curriculum and service-based learning.

CONCLUSION

There are differences in the gerodontology curricula of dental schools, with a wide variation of clinical exposure to older patients. There is evidence that exposure to gerodontology curriculum prior to treating older people may help dental students feel more prepared for managing patients in aged care. The current marginal status of gerodontology in dental school curricula is in need of review.

Short Telomere Length Is Related to Limitations in Physical Function in Elderly European Adults

The present study aims to explore the potential influence of leucocyte telomere length (LTL) on both a single indicator and a composite construct of physical functioning in a large European population of elderly men and women across diverse geographical locations. A total of 1,221 adults (65–79 years) were recruited from five European countries within the framework of NU-AGE study. The physical functioning construct was based on the 36-item Short Form Health Survey. Handgrip strength was used as a single indicator of muscle function and LTL was assessed using quantitative real-time PCR. Women had significantly longer (p < 0.05) LTL than men. Participants in Poland had significantly shorter LTL than in the other study centers, whereas participants in the Netherlands had significantly longer LTL than most of the other centers (p < 0.01). An analysis of LTL as a continuous outcome against physical functioning by using linear models revealed inconsistent findings. In contrast, based on an analysis of contrasting telomere lengths (first vs. fifth quintile of LTL), a significant odds ratio (OR) of 1.7 (95% CI: 1.1 – 2.6; p < 0.05) of having functional limitation was observed in those belonging to the first LTL quintile compared to the fifth. Interestingly, having the shortest LTL was still related to a higher likelihood of having physical limitation when compared to all remaining quintiles (OR: 1.5, 95% CI: 1.1 – 2.1; p < 0.05), even after adjustment by study center, age, sex, and overweight status. Collectively, our findings suggest that short LTL is an independent risk factor that accounts for functional decline in elderly European populations. The influence of LTL on functional limitation seems driven by the detrimental effect of having short telomeres rather than reflecting a linear dose-response relationship.

A new stocking compression system with a low well-defined resting pressure and a high working pressure

Not available