Frailty in younger adults in hospital

BACKGROUND

Even though frailty has been extensively measured in the acute care setting, relatively little is known about the frailty of younger adult inpatients.

AIM

This study aimed to measure frailty in a sample of hospitalized adults aged 18 years and over and to examine how frailty in younger adult inpatients differs from middle-aged and older adult inpatients.

DESIGN

Secondary analyses of prospectively collected cohort data.

METHODS

Research nurses assessed 910 patients at admission to four Australian hospitals using the interRAI Acute Care instrument. Comparison of frailty index (FI) scores and domains was conducted across three age groups: younger (18-49 years), middle-aged (50-69 years) and older adults (≥70 years). Multivariable logistic regression examined risk of prolonged length of stay and unfavourable discharge destination.

RESULTS

Younger adults (n = 214; 23.5%) had a mean (SD) FI of 0.19 (0.10). Approximately 27% (n = 57) of younger adults were frail (FI > 0.25). Mood and behaviour, health symptoms and syndromes, nutrition and pain were the most frequently affected domains in younger adults and 50% had ≥3 comorbidities. Frailty increased the risk of long length of stay (odds ratio (OR) = 1.77, P < 0.001) but not the risk of an unfavourable discharge (OR = 1.40, P = 0.20) in younger adults.

CONCLUSIONS

This study showed that frailty is prevalent in younger patients admitted to acute care and is associated with adverse outcomes. This study was a critical first step towards establishing an understanding of frailty in younger hospitalized adults.

Spatial-extent inference for testing variance components in reliability and heritability studies

Clusterwise inference is a popular approach in neuroimaging to increase sensitivity, but most existing methods are currently restricted to the General Linear Model (GLM) for testing mean parameters. Statistical methods for testing variance components, which are critical in neuroimaging studies that involve estimation of narrow-sense heritability or test-retest reliability, are underdeveloped due to methodological and computational challenges, which would potentially lead to low power. We propose a fast and powerful test for variance components called CLEAN-V (CLEAN for testing Variance components). CLEAN-V models the global spatial dependence structure of imaging data and computes a locally powerful variance component test statistic by data-adaptively pooling neighborhood information. Correction for multiple comparisons is achieved by permutations to control family-wise error rate (FWER). Through analysis of task-fMRI data from the Human Connectome Project across five tasks and comprehensive data-driven simulations, we show that CLEAN-V outperforms existing methods in detecting test-retest reliability and narrow-sense heritability with significantly improved power, with the detected areas aligning with activation maps. The computational efficiency of CLEAN-V also speaks of its practical utility, and it is available as an R package.

Interpopulation differences and temporal synchrony in rates of adult survival between two seabird colonies that differ in population size and distance to foraging grounds

Understanding the processes that drive interpopulation differences in demography and population dynamics is central to metapopulation ecology. In colonial species, populations are limited by local resource availability. However, individuals from larger colonies will travel greater distances to overcome density-dependent competition. Consequently, these individuals may also experience greater carry-over effects and interpopulation differences in demography. To test this prediction, we use mark-recapture data collected over four decades from two breeding colonies of a seabird, the Manx shearwater (Puffinus puffinus), that exhibit strong spatial overlap throughout the annual cycle but differ in population size and maximum foraging distances. We quantify interpopulation differences and synchrony in rates of survival and assess whether local mean wind speeds act to strengthen or disrupt synchrony. In addition, we examine whether the imputed interpopulation differences in survival can generate population-level consequences. The colony where individuals travel further during the breeding season had slightly lower and more variable rates of survival, indicative of individuals experiencing greater carry-over effects. Fluctuations in survival were highly synchronous between the colonies, but neither synchronous, nor asynchronous, variation could be strongly attributed to fluctuations in local mean wind speeds. Finally, we demonstrate that the imputed interpopulation differences in rates of survival could lead to considerable differences in population growth. We hypothesise that the observed interpopulation differences in rates of adult survival reflect carry-over effects associated with foraging distances during the breeding season. More broadly, our results highlight that breeding season processes can be important for understanding interpopulation differences in the demographic rates and population dynamics of long-lived species, such as seabirds.

On inference in high-dimensional regression

This paper develops an approach to inference in a linear regression model when the number of potential explanatory variables is larger than the sample size. The approach treats each regression coefficient in turn as the interest parameter, the remaining coefficients being nuisance parameters, and seeks an optimal interest-respecting transformation, inducing sparsity on the relevant blocks of the notional Fisher information matrix. The induced sparsity is exploited through a marginal least-squares analysis for each variable, as in a factorial experiment, thereby avoiding penalization. One parameterization of the problem is found to be particularly convenient, both computationally and mathematically. In particular, it permits an analytic solution to the optimal transformation problem, facilitating theoretical analysis and comparison to other work. In contrast to regularized regression, such as the lasso and its extensions, neither adjustment for selection nor rescaling of the explanatory variables is needed, ensuring the physical interpretation of regression coefficients is retained. Recommended usage is within a broader set of inferential statements, so as to reflect uncertainty over the model as well as over the parameters. The considerations involved in extending the work to other regression models are briefly discussed.

A New Class of Weighted CUSUM Statistics

A change point is a location or time at which observations or data obey two different models: before and after. In real problems, we may know some prior information about the location of the change point, say at the right or left tail of the sequence. How does one incorporate the prior information into the current cumulative sum (CUSUM) statistics? We propose a new class of weighted CUSUM statistics with three different types of quadratic weights accounting for different prior positions of the change points. One interpretation of the weights is the mean duration in a random walk. Under the normal model with known variance, the exact distributions of these statistics are explicitly expressed in terms of eigenvalues. Theoretical results about the explicit difference of the distributions are valuable. The expansions of asymptotic distributions are compared with the expansion of the limit distributions of the Cramér-von Mises statistic and the Anderson and Darling statistic. We provide some extensions from independent normal responses to more interesting models, such as graphical models, the mixture of normals, Poisson, and weakly dependent models. Simulations suggest that the proposed test statistics have better power than the graph-based statistics. We illustrate their application to a detection problem with video data.

How frail is frail? A systematic scoping review and synthesis of high impact studies

AIMS

While the frailty index (FI) is a continuous variable, an FI score of 0.25 has construct and predictive validity to categorise community-dwelling older adults as frail or non-frail. Our study aimed to explore which FI categories (FI scores and labels) were being used in high impact studies of adults across different care settings and why these categories were being chosen by study authors.

METHODS

For this systematic scoping review, Medline, Cochrane and EMBASE databases were searched for studies that measured and categorised an FI. Of 1314 articles screened, 303 met the eligibility criteria (community: N = 205; residential aged care: N = 24; acute care: N = 74). For each setting, the 10 studies with the highest field-weighted citation impact (FWCI) were identified and data, including FI scores and labels and justification provided, were extracted and analysed.

RESULTS

FI scores used to distinguish frail and non-frail participants varied from 0.12 to 0.45 with 0.21 and 0.25 used most frequently. Additional categories such as mildly, moderately and severely frail were defined inconsistently. The rationale for selecting particular FI scores and labels were reported in most studies, but were not always relevant.

CONCLUSIONS

High impact studies vary in the way they categorise the FI and while there is some evidence in the community-dweller literature, FI categories have not been well validated in acute and residential aged care. For the time being, in those settings, the FI should be reported as a continuous variable wherever possible. It is important to continue working towards defining frailty categories as variability in FI categorisation impacts the ability to synthesise results and to translate findings into clinical practice.

The effect of heavy prenatal alcohol exposure on adolescent body mass index and waist-to-height ratio at 12-13 years

BACKGROUND

Growing evidence suggests that prenatal alcohol exposure (PAE) has the potential to impact on a wide range of physical outcomes in offspring, including metabolism and body composition, although the evidence to-date is primarily from preclinical studies. The current clinical study examined the association between heavy PAE and indirect measures of adiposity in adolescence.

METHODS

Analyses drew on data from the Longitudinal Study of Australian Children, a national prospective cohort of children and their families from birth to adolescence. Participants included children with heavy PAE (≥70 g/week; n = 46), measured via maternal self-report of alcohol use during pregnancy and a comparison group of children without any PAE (n = 782), frequency matched on sex, ethnicity and socio-economic position. Body mass index (BMI) z-scores, waist-to-height ratios and proportion overweight/obese were calculated from height, weight and waist circumference measured at age 12-13 years. Two (PAE) × two (sex) ANCOVA and logistic regression models were performed, controlling for matching variables, adolescent age, pubertal status and birthweight; maternal age at birth and smoking during pregnancy.

RESULTS

Female adolescents with heavy PAE during late pregnancy had significantly higher BMI z-scores (M = 0.75, SD = 0.69) and proportion overweight/obese (38.5%) than females not exposed to any prenatal alcohol (M = 0.29, SD = 1.07, P = 0.04; 23.8%, P = 0.03, respectively). There was no significant effect of heavy PAE on male adolescent BMI z-scores and proportion overweight/obese or adolescent waist-to-height ratios (all P > 0.05).

CONCLUSIONS

Heavy PAE had a sex-specific effect on measures of adiposity in early adolescence, with girls more likely to have increased BMI and overweight/obesity status. Further longitudinal follow-up of children exposed to PAE is required to confirm if maternal alcohol consumption is a risk factor for later life obesity.

Alterations to Placental Glucocorticoid Receptor Expression with Alcohol Consumption

Maternal alcohol consumption during pregnancy results in elevated vulnerability to intrauterine growth restriction, preterm birth, miscarriage, and stillbirth. Many of the detrimental effects of fetal alcohol exposure may be mediated through placental dysfunction; however, the exact mechanisms remain unknown. Here, we aimed to determine the effect of maternal alcohol exposure prior to and during early pregnancy on placental glucocorticoid receptor (GR) isoforms, associated GR regulated genes, and infant outcomes. Participants carrying singleton fetuses (n = 113) were recruited during early pregnancy. Amount and type of alcohol consumed over the last 12 months were obtained at 18 weeks of gestation. The level of drinking was separated into none (0 g/day), low (< 10 g/day), moderate (10-100 g/day), and heavy (> 100 g/day). At delivery, placental weight, infant sex, birthweight, and head circumference were recorded. Placental GR isoforms and genes involved in downstream signalling pathways were quantified. The majority of women (70.8%) consumed alcohol. Of these, most consumed low (48.8%) or moderate (37.5%) amounts. Placental weight was unaffected by alcohol consumption, but infants born to heavy drinkers tended to be lighter at birth. In female, but not male, placentae, maternal alcohol consumption resulted in increased GRαC and decreased GRαD1 cytoplasmic expression. In both female and male placentae, a dampened inflammatory response was evident with maternal alcohol consumption, involving downregulated IL6R and upregulated POU2F2 gene expression, respectively. Maternal alcohol consumption in the months prior to, and/or during early, pregnancy alters placental GR isoform and expression of some inflammatory genes in a sex-specific manner.

On specification tests for composite likelihood inference

Composite likelihood functions are often used for inference in applications where the data have a complex structure. While inference based on the composite likelihood can be more robust than inference based on the full likelihood, the inference is not valid if the associated conditional or marginal models are misspecified. In this paper, we propose a general class of specification tests for composite likelihood inference. The test statistics are motivated by the fact that the second Bartlett identity holds for each component of the composite likelihood function when these components are correctly specified. We construct the test statistics based on the discrepancy between the so-called composite information matrix and the sensitivity matrix. As an illustration, we study three important cases of the proposed tests and establish their limiting distributions under both null and local alternative hypotheses. Finally, we evaluate the finite-sample performance of the proposed tests in several examples.

Parent-reported sleep problems in school-aged children with fetal alcohol spectrum disorder: association with child behaviour, caregiver, and family functioning

OBJECTIVE/BACKGROUND

Sleep problems are a common clinically reported area of concern for children and adolescents with fetal alcohol spectrum disorder (FASD). However, limited empirical research has been undertaken investigating sleep problems for children with FASD. The current study aimed to examine the associations between parent-reported sleep problems in children with FASD and child behaviour, caregiver mental health and health-related quality of life and family functioning.

PARTICIPANTS

163 caregivers of children diagnosed with FASD aged 5-17 years were included in the current study.

METHOD

Cross-sectional online survey that collected information pertaining to child sleep problems (difficulty falling asleep, difficulty staying asleep and/or frequent waking during the night and waking early in the morning) and standardised caregiver reported measures of child behaviour, caregiver mental wellbeing, caregiver health-related quality of life, and family functioning.

RESULTS

Sleep problems were common, affecting 65.6% (n = 107) of participants. Difficulty falling asleep (56.4%) was the most common sleep problem encountered, followed by difficulty staying asleep (44.8%) and waking early (29.4%). Sleep problems were associated with increased rates of child behaviour problems and caregiver anxiety and negative impacts on caregiver and family quality of life.

CONCLUSION

Sleep problems in children and adolescents with FASD are common and associated with poorer child, caregiver and family outcomes. Future research needs to determine whether effective identification and management of sleep problems can reduce adverse outcomes.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Caregiver and family quality of life for children with fetal alcohol spectrum disorder

BACKGROUND

Fetal alcohol spectrum disorder (FASD) is a common neurodevelopmental condition. Given that individuals with FASD can experience lifelong challenges, one field of research that could be applicable is the paediatric chronic health literature.

AIMS

The aim of the current study was to investigate the utility of the Pediatric Quality of Life Inventory (PedsQL) Family Impact Module, designed to measure the impact of paediatric chronic health conditions on caregivers and families.

METHODS AND PROCEDURES

109 caregivers of children with FASD completed an online survey that assessed a range of areas including, caregiver and family quality of life, caregiver mental health and child behaviour.

OUTCOMES AND RESULTS

Overall, caregivers reported the areas most impacted on the PedsQL module were Family Daily Activities and Worry. Caregiver's country of residence, mental health, child gender, and level of child behaviour problems were found to be predictors of caregiver and family quality of life.

CONCLUSIONS AND IMPLICATIONS

The results demonstrate that there are multidimensional challenges for caregivers and families. These findings have important implications for policy and practice regarding the provision of supports and services for children with FASD and their families.

Adverse reproductive outcomes associated with fetal alcohol exposure: a systematic review

Fetal alcohol exposure results in well-characterised neurobehavioural deficits in offspring, which form the basis for diagnosing fetal alcohol spectrum disorder. However, there is increasing interest in the full range of health complications that can arise in children and adults with this disorder. We used a systematic review approach to locate all clinical and preclinical studies across a broad range of health outcomes in offspring exposed to prenatal alcohol. Our search encompassed four databases (PubMed, CINAHL, EMBASE and Web of Science) and titles/abstracts from retrieved studies were screened against strict inclusion/exclusion criteria. This review specifically evaluated studies reporting on reproductive outcomes in both males and females. A total of 23 studies were included, 5 clinical and 18 preclinical. Although there was a wide range in the quality of reporting across both clinical and preclinical studies, and variable results, trends emerged amongst the reproductive measures that were investigated. In females, most studies focussed on age at first menarche/puberty onset, with evidence for a significant delay in alcohol-exposed offspring. In males, offspring exposed to prenatal alcohol had altered testosterone levels, reduced testes and accessory gland weights and reduced sperm concentration and semen volume. However, further studies are required due to the paucity of clinical studies, the narrow scope of female reproductive outcomes examined and inconsistencies in outcomes across preclinical studies. We recommend that adolescents and individuals of reproductive age diagnosed with f-etal alcohol spectrum disorder be assessed for reproductive dysfunction to allow appropriate management of their reproductive health and fertility.

Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education

BACKGROUND

Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities.

AIM

To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education.

METHODS

A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017.

FINDINGS

A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals.

CONCLUSION

Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.

Association of sitting time and breaks in sitting with muscle mass, strength, function, and inflammation in community-dwelling older adults

The mechanisms through which excessive sitting time impacts health are important to understand. This study found that each hour of sitting per day was not associated with physical function, although associations with poor body composition were observed. Reducing sitting time for improved weight management in older adults needs further exploration.

INTRODUCTION

To examine the association of sitting time and breaks in sitting time with muscle mass, strength, function, and inflammation in older Australians.

METHODS

Data from the thigh-worn activPAL3™ monitor (7-day continuous wear) was used to derive time spent sitting (hours) and total number of sit-stand transitions per day. Body composition (dual energy X-ray absorptiometry), lower-body muscle strength, function (timed up-and-go [TUG], 4-m gait speed, four square step test, 30-second sit-to-stand), and serum inflammatory markers (interleukin-[IL-6], IL-8, IL-10, tumor necrosis factor-alpha [TNF-α], and adiponectin) were measured. Multiple regression analyses, adjusted for age, sex, ethnicity, education, employment status, marital status, number of prescription medications, smoking status, vitamin D, and stepping time, were used to assess the associations.

RESULTS

Data from 123 community-dwelling older adults (aged 65-84 years, 63% female) were used. Total daily sitting time was associated with lower percentage lean mass (β [95%CI], - 1.70% [- 2.30, - 1.10]) and higher total body fat mass (2.92 kg [1.94, 3.30]). More frequent breaks in sitting time were associated with a 45% reduced risk of having pre-sarcopenia (OR = 0.55; 95% CI 0.34, 0.91; model 1), defined as appendicular lean mass divided by BMI. No significant associations were observed for sitting time or breaks in sitting with measures of muscle strength, function, or inflammation.

CONCLUSION

In older community-dwelling adults, greater sitting time was associated with a lower percentage lean mass, while more frequent breaks in sitting time were associated with lower odds of having pre-sarcopenia. This suggests that reducing sedentary time and introducing frequent breaks in sedentary time may be beneficial for improving body composition in healthy older adults.

High soil acidity under native shrub encroachment in the Cobar Pediplain, south-eastern Australia

This study investigated the chemical characteristics of shallow (0–30 cm) soil profiles under shrubs in areas of dense encroachment and compared them with shallow soil profiles under nearby large trees. Consistent patterns of high soil acidity were found under shrubs, as well as lower litter alkalinity, lower relative concentrations of calcium (Ca2+), lower effective cation exchange capacity, and higher aluminium (Al3+) and sodium (Na+) in the soil profile compared with under trees. Soil pH (CaCl2) was strongly correlated with the Ca content of surface litter. These findings suggest that shrubs (which at most sites included the shrub form of tree species) cycle alkalinity differently from large and mature trees, resulting in high acidity in the shallow soil profile acidity, and possible loss of alkalinity via surface movement of material from areas of dense encroachment.

Excessive sulphur accumulation and ionic storage behaviour identified in species of Acacia (Leguminosae: Mimosoideae)

BACKGROUND AND AIMS

Thiophores, which are typically desert gypsophytes, accumulate high (2-6 % S dry weight) sulphur concentrations and may possess unique tolerance to environmental stress factors, e.g. sulphate/metal toxicity, drought and salinity. Little is known of the prevalence of the behaviour or the associated physiological aspects. The aim of this study was to (a) determine the prevalence of thiophore behaviour in a group of Australian xerophytes; (b) identify elemental uptake/storage characteristics of these thiophores; and (c) determine whether the behaviour is constitutive or environmental.

METHODS

The elemental composition of soils and the foliage of 11 species (seven genera) at a site in the Tanami Desert (NT, Australia) was compared and 13 additional Acacia species from other locations were examined for elevated calcium and sulphur concentrations and calcium-sulphur mineralization, thought to be particular to thiophores.

KEY RESULTS

Acacia bivenosa DC. and 11 closely related species were identified as thiophores that can accumulate high levels of sulphur (up to 3·2 %) and calcium (up to 6.8 %), but no thiophores were identified in other genera occupying the same habitat. This behaviour was observed in several populations from diverse habitats, from samples collected over three decades. It was also observed that these thiophores featured gypsum (CaSO4·2H2O) crystal druses that completely filled cells and vascular systems in their dried phyllode tissues.

CONCLUSIONS

The thiophores studied exhibit a tight coupling between sulphur and calcium uptake and storage, and apparently store these elements as inorganic salts within the cells of their foliage. Thiophore behaviour is a constitutive trait shared by closely related Acacia but is not highly prevalent within, nor exclusive to, xerophytes. Several of the newly identified thiophores occupy coastal or riparian habitats, suggesting that the evolutionary and ecophysiological explanations for this trait do not lie solely in adaptation to arid conditions or gypsiferous soils.

Reducing occupational sedentary time: a systematic review and meta-analysis of evidence on activity-permissive workstations

Excessive sedentary time is detrimentally linked to obesity, type 2 diabetes, cardiovascular disease and premature mortality. Studies have been investigating the use of activity-permissive workstations to reduce sedentary time in office workers, a highly sedentary target group. This review systematically summarizes the evidence for activity-permissive workstations on sedentary time, health-risk biomarkers, work performance and feasibility indicators in office workplaces. In July 2013, a literature search identified 38 relevant peer-reviewed publications. Key findings were independently extracted by two researchers. The average intervention effect on sedentary time was calculated via meta-analysis. In total, 984 participants across 19 field-based trials and 19 laboratory investigations were included, with sample sizes ranging from n = 2 to 66 per study. Sedentary time, health-risk biomarkers and work performance indicators were reported in 13, 23 and 23 studies, respectively. The pooled effect size from the meta-analysis was -77 min of sedentary time/8-h workday (95% confidence interval = -120, -35 min). Non-significant changes were reported for most health- and work-related outcomes. Studies with acceptability measures reported predominantly positive feedback. Findings suggest that activity-permissive workstations can be effective to reduce occupational sedentary time, without compromising work performance. Larger and longer-term randomized-controlled trials are needed to understand the sustainability of the sedentary time reductions and their longer-term impacts on health- and work-related outcomes.