Influence of Nutritional Status on a Family-Centered Care Intervention for Older Adults with Cognitive Impairment following Hip-Fracture Surgery: Secondary Data Analysis of a Randomized Controlled Trial

OBJECTIVES

In Taiwan, older adults with cognitive impairment who undergo hip-fracture surgery are routinely cared for by family members. This study aimed to determine if nutritional status influenced the effects of a family-centered intervention for older adults with cognitive impairment recovering from hip-fracture surgery.

DESIGN

Secondary data analysis of data from a randomized controlled trial was conducted to examine the influences of nutritional status 1 month after hospital discharge on the effects of a family-centered care intervention model, which was designed for older adults with hip fracture and cognitive impairment. Outcomes were compared among participants according to nutrition status (well-nourished/poorly-nourished) and treatment approach (control/intervention).

SETTING

The original study was conducted at a 3000-bed medical center from July 2015 to October 2019.

PARTICIPANTS

Participants were older adults with cognitive impairment who had undergone hip-fracture surgery. Participants were assessed as poorly-nourished or well-nourished with the Mini-Nutritional Assessment (MNA) 1-month post-discharge and were then randomly assigned to either the intervention group or control group.

INTERVENTION

A family-centered intervention model for family caregivers of older adults with cognitive impairment recovering from hip-fracture surgery was implemented. The intervention was delivered by geriatric nurses, which included instructions for family caregivers in overseeing exercises for strengthening the hip, understanding dietary requirements, and managing behavioral problems associated with cognitive impairment.

MEASUREMENTS

Outcome measures included activities of daily living (ADLs), instrumental ADLs, hip range of motion, hip muscle strength, depression, measured with the Geriatric Depressive Scale, and physical and mental health related quality of life, measured with the Short Form Survey (SF-36), Taiwanese version. Participants were assessed at 1-, 3-, 6-, and 12-months post-discharge.

RESULTS

Most of the 134 participants were assessed as poorly nourished (n = 122); 57 were the control group and 65 received the intervention. For the well-nourished participants (n = 12), four were in the intervention group and eight were controls. There were no significant differences in any outcome variables for poorly nourished participants who received the intervention compared with controls. For the sample of well-nourished participants, those who received the intervention performed significantly better in outcomes of IADLs (b = 1.74, p < .05), hip muscle strength (b = 9.64, p < .01), and physical health related quality of life (b = 10.47, p < .01).

CONCLUSION

The family-centered care intervention was only effective for older adults with cognitive impairment recovering from hip-fracture surgery who were well-nourished at 1 month following hospital discharge, but not for those at risk of malnutrition. Interventions should focus on enhancing nutritional status following hip surgery which could allow the family-centered in-home intervention to be beneficial for more older adults with cognitive impairment recovering from hip-fracture surgery.

Summary of evidence on immediate statins therapy following aneurysmal subarachnoid hemorrhage

Statins were shown to have neuroprotective effects, with reduced vasospasm and delayed ischemic deficits in statin-treated patients after aneurysmal subarachnoid hemorrhage in two small, randomized, controlled clinical trials published in 2005. This review consolidated data from available published studies evaluating statin treatment for subarachnoid hemorrhage. A literature search was conducted to identify original research studies published through October 2010 testing immediate treatment with a statin in statin-naïve patients following aneurysmal SAH. Six randomized controlled clinical trials and four observational studies were identified. Despite inconsistent results among studies, a meta-analysis of randomized controlled data showed a significant reduction in delayed ischemic deficits with statins. Effect on vasospasm was more difficult to determine, due to differences in definitions used among studies. Interpretations from observational studies were limited by the use of relatively small sample sizes, historical controls, and treatment variability.

Cerebral blood flow augmentation in patients with severe subarachnoid haemorrhage

Following aneurysmal subarachnoid haemorrhage (SAH), cerebral blood flow (CBF) may be reduced, resulting in poor outcome due to cerebral ischaemia and subsequent stroke. Hypertonic saline (HS) is known to be effective in reducing intracranial pressure (ICP). We have previously shown a 20-50% increase in CBF in ischaemic regions after intravenous infusion of HS. This study aims to determine the effect of HS on CBF augmentation, substrate delivery and metabolism. Continuous monitoring of arterial blood pressure (ABP), ICP, cerebral perfusion pressure (CPP), brain tissue oxygen (PbO2), middle cerebral artery flow velocity (FV), and microdialysis was performed in 14 poor grade SAH patients. Patients were given an infusion of 23.5% HS, and quantified xenon computerised tomography scanning (XeCT) was carried out before and after the infusion in 9 patients. The results showed a significant increase in ABP, CPP, FV and PbO2, and a significant decrease in ICP (p < 0.05). Nine patients showed a decrease in lactate-pyruvate ratio at 60 minutes following HS infusion. These results show that HS safely and effectively augments CBF in patients with poor grade SAH and significantly improves cerebral oxygenation. An improvement in cerebral metabolic status in terms of lactate-pyruvate ratio is also associated with HS infusion.

Thoracoscopic sympathectomy for palmar hyperhidrosis: effects on pulmonary function

Palmar hyperhidrosis, probably caused by an over-reactivity of sympathetic nerves passing through the second and the third thoracic sympathetic ganglia (T2 & T3 ganglia), can only be cured by sympathectomy. Such sympathetic denervation may also alter pulmonary function. Previous studies have shown that open sympathectomy can cause significant deterioration in pulmonary function, however, the surgical procedure itself may contribute to the change. Recently thoracoscopic sympathectomy has been developed as a minimally invasive but effective treatment for palmar hyperhidrosis. In order to investigate the effect of sympathectomy, pulmonary function was compared before and four weeks after operation in 20 patients. Forced vital capacity (FVC) (-2.3%), forced expiratory volume in one second (FEV1) (-6.1%), and FEV1/FVC (-4.6%) were all slightly but significantly decreased four weeks after thoracoscopic sympathectomy. Also the instantaneous forced expiratory flow at 75%, 50% and 25% of the FVC (Vmax25, Vmax50, Vmax75) in flow-volume curves were decreased (-1.6%, -8.4%, and -20% respectively). Therefore, thoracoscopic sympathectomy minimises pulmonary restrictive effects but allows subclinical small airway obstructive effects to become more evident.

Endoscopic extraperitoneal lumbar sympathectomy for plantar hyperhidrosis: case report

A right sided endoscopic retroperitoneal lumbar sympathectomy was performed on a 23 year old female who had plantar hyperhidrosis. After the operation, the right foot temperature increased and the plantar hyperhidrosis was relieved. During the follow up period, both feet were warm and dry, although only the right side lumbar sympathectomy had been performed. The outcome appeared to be compatible with that of an open procedure but with minimal invasiveness.

[Changes in discharge needs and satisfaction of family caregivers of frail elders during the discharge transition]

This longitudinal study was designed to explore the discharge needs and needs satisfaction of frail elders' family caregivers during the discharge transition. A total of 131 pairs of frail elders and their family caregivers from neuro-medical wards in a teaching hospital in northern Taiwan were interviewed using a structured questionnaire. Descriptive statistics, paired t-test, and repeated measure ANOVA were used to analyze the data. The results showed that: (1) The total needs and specific needs were higher before discharge than one week and one month after discharge. The rank order of the discharge needs, from high to low, was health care information services, health care services, emotional support services, and manpower support services. (2) The needs satisfaction at one week after discharge was the same as at one month after discharge. The rank order of needs satisfaction, from high to low, was health care services, health care information services, manpower support services, and emotional support services. The findings of this study suggest that during the discharge transition before discharge is the time of most needs and is an important time for developing nursing interventions. The "caregiver discharge needs and satisfaction assessment tool" can be used in clinical for practice assessment of the discharge needs and needs satisfaction of frail elders' family caregivers during the dis-charge transition.

Experience in surgical management of tumours involving the cavernous sinus

Potential injury to the neurovascular structures within the cavernous sinus often prohibits aggressive removal of tumours involving it, however, fully understanding the anatomy and selecting an appropriate surgical approach can often resolve this problem with acceptable morbidity. Moreover, a tumour may originate from different anatomical structures of the cavernous sinus which will influence the difficulty and outcome of the surgery. In general, tumours in this region can be classified as intradural, intracavernous and invasive types. The strategy of surgical treatment varies among these different anatomical types. Therefore, preoperative evaluation of tumours in the cavernous sinus is critical for the selection of an appropriate microsurgical approach. During the past 5 years, 12 tumours involving the cavernous sinus have been operated upon which included four neuromas, three meningiomas, three cavernous haemangiomas, one plasmacytoma and one chondroma. Nine of these twelve tumours were totally resected after one or two operations. There was no surgical mortality and the most common morbidity was transient cranial nerve palsy. At 2 months after surgery there was no additional postoperative cranial nerve deficit in all the patients; however, one patient developed a postoperative middle cerebral artery infarct due to accidental injury to the internal carotid artery during surgery. The respectability of the tumour mostly depends on its consistency and the involvement of the adjacent anatomy. The pathoanatomical features of the tumours and the clinicoradiological findings, as well as the selection of the microsurgical approach, are discussed.

Recurrent intracerebral hemorrhages in cerebral amyloid angiopathy: a case report

Cerebral amyloid angiopathy frequently causes recurrent intracerebral hemorrhages in elderly patients who do not have systemic hypertension. Surgery should be reserved for conditions which cannot be controlled by medical treatment. When surgery is needed, potential complications (such as bleeding near the operation site or remote area) should be kept in mind. A case study of a 66-year-old woman with cerebral amyloid angiopathy and recurrent intracerebral hemorrhages is presented.

Isolated leptomeningeal tuberculoma

Intracranial leptomeningeal tuberculoma without evidence of systemic tuberculosis is rarely encountered and is often difficult to diagnose because there are no specific signs or symptoms. A 49-year-old woman, without any past history of tuberculosis, presented with weakness and focal seizures in the right hand. Cranial magnetic resonance imaging revealed a leptomeningeal lesion in the left frontoparietal region. All conventional examinations demonstrated no evidence of tuberculous infection. The patient underwent biopsy, and histopathologic examination showed caseating granulomas compatible with tuberculomas. The culture of the surgical specimen grew Mycobacterium tuberculosis 4 weeks later. The patient was then actively treated with antituberculous agents for 1 year. Subsequent clinical features and image studies showed the intracranial lesion in resolution. The findings of this case argue in favor of surgical biopsy when intracranial tuberculosis is clinically suspected, even without evidence of systemic tuberculous infection.

A novel role of ImmE7 in the autoregulatory expression of the ColE7 operon and identification of possible RNase active sites in the crystal structure of dimeric ImmE7

Site-specific cleavage of mRNA has been identified in vivo for the polycistronic colicin E7 operon (ColE7), which occurs between G and A nucleotides located at the Asp52 codon (GAT) of the immunity gene (ceiE7). In vitro, this specific cleavage occurs only in the presence of the ceiE7 gene product (ImmE7). The crystal structure of dimeric ImmE7 has been determined at 1.8 A resolution by X-ray crystallographic analysis. We found that several residues located at the interface of dimeric ImmE7 bear surprising resemblance to the active sites of some RNases. These results suggest that dimeric ImmE7 may possess a novel RNase activity that cleaves its own mRNA at a specific site and thus autoregulates translational expression of the downstream celE7 gene as well as degradation of the upstream ceaE7 mRNA.

Expression of the crystal protein gene under the control of the alpha-amylase promoter in Bacillus thuringiensis strains

The expression of an insecticidal crystal protein gene of Bacillus thuringiensis under the control of the alpha-amylase gene promoter was investigated. The cryIC gene, which encodes a protein known to have a unique activity against Spodoptera (armyworm) species, was used in this investigation. The cryIC gene was placed, along with the alpha-amylase promoter from B. subtilis, in a B. thuringiensis-derived cloning vector, generating a pair of recombinant plasmids, pSB744 and pSB745. The cloning vector that contains the minimal replicon of B. thuringiensis subsp. kurstaki HD73 is stably maintained in a variety of B. thuringiensis strains, as previously reported by Gamel and Piot (Gene 120:17-26, 1992). The present study confirmed that the recombinant plasmids are also stably maintained in B. thuringiensis subsp. kurstaki Cry-B and HD73 growing in media without selection pressure for at least 48 h. The cryIC gene on the recombinant plasmids were notably expressed at high levels in both recombinant strains. Expression of the introduced cryIC gene on the recombinant plasmid in B. thuringiensis subsp. kurstaki HD73 did not impair expression of the resident cryIA(c) gene. The CryIA(c) protein is known to have a high level of activity against loopers such as Trichoplusia ni (the cabbage looper). As a result of coexpression of the introduced cryIC gene and the resident cryIA(c) gene, recombinant strain HD73 acquired an additional insecticidal activity against Spodoptera exigua (the beet armyworm) whereas the original activity level against T. ni was maintained.

Determination and Distribution of cry -Type Genes of Bacillus thuringiensis Isolates from Taiwan

Using PCR with a set of specific oligonucleotide primers to detect cryI -type genes, we were able to screen the cry -type genes of 225 Bacillus thuringiensis soil isolates from Taiwan without much cost in time or labor. Some combinations of cry genes (the cry -type profile) in a single isolate were unique. We identified five distinct profiles of crystal genes from the B. thuringiensis soil isolates from Taiwan. The cry genes included cryIA ( a ), cryIA ( b ), cryIA ( c ), cryIC, cryID , and cryIV . Interestingly, 501 B. thuringiensis isolates (93.5% of the total number that we identified) were isolated from areas at high altitudes. The profiles of cry -type genes were distinct in all isolation areas. The distribution of cry -type genes of our isolates therefore depended on geography. Using PCR footprinting to detect cryIC -type genes, we identified two distinct cryIC footprints from some of our isolates, indicating that these isolates may contain novel cryIC -type genes. B. thuringiensis isolates containing cryIA ( a )-, cryIA ( b )-, and cryIA ( c )-type genes exhibited much greater activity against Plutella xylostella than did other isolates, indicating that multiple cry -type genes may be used as markers for the prediction of insecticidal activities.