Blood-brain barrier (BBB) disruption has long been recognised as an important early feature of multiple sclerosis (MS) pathology. Traditionally, this has been seen as a by-product of the ...myelin-specific immune response. Here, we consider whether vascular changes instead play a central role in disease pathogenesis, rather than representing a secondary effect of neuroinflammation or neurodegeneration. Importantly, this is not necessarily mutually exclusive from current hypotheses. Vascular pathology in a genetically predisposed individual, influenced by environmental factors such as pathogens, hypovitaminosis D and smoking, may be a critical initiator of a series of events including hypoxia, protein deposition and immune cell egress that allows the development of a CNS-specific immune response and the classical pathological and clinical hallmarks of disease. We review the changes that occur in BBB function and cerebral perfusion in patients with MS and highlight genetic and environmental risk factors that, in addition to modulating immune function, may also converge to act on the vasculature. Further context is provided by contrasting these changes with other neurological diseases in which there is also BBB malfunction, and highlighting current disease-modifying therapies that may also have an effect on the BBB. Indeed, in reframing current evidence in this model, the vasculature could become an important therapeutic target in MS.
Aim
Room service is a patient‐focused foodservice model gaining interest in Australian hospitals following demonstrated patient and organisational benefits. This study aimed to compare nutritional ...intake, waste, patient satisfaction, meal costs and meal quality between a bought‐in, thaw‐retherm foodservice model and a cook‐fresh, on‐demand room service model at a large tertiary public hospital.
Methods
A retrospective analysis of quality assurance data compared thaw‐retherm to room service. Nutritional intake and plate waste were measured using a visual intake analysis tool; production waste was measured using weighted analysis methodology; patient satisfaction was measured using a validated patient satisfaction survey; meal quality was assessed using a validated meal quality audit tool, and meal costs were obtained from hospital finance reports. Independent sample t‐tests or nonparametric equivalent (Mann‐Whitney U‐test) for continuous variables and Pearson's Chi‐square for categorical data were applied for comparative purposes.
Results
Average energy and protein intake, as well as percentage requirements met, improved between thaw‐retherm and room service (4320 kJ/day vs 7265 kJ/day; 42.4 g/day vs 82.5 g/day; and 46% vs 80.7%; 49.9% vs 98.4%; all P < .001. Reductions in plate waste (40% vs 15%) and production waste (15% vs 5.6%, P < .001) were observed and food costs decreased by 9% with room service. Meal quality audit results improved, and patient satisfaction increased with % respondents satisfied increasing from 75.0% to 89.8% (χ2 9.9852; P = .007) for room service.
Conclusions
This research demonstrates significant improvements in patient and organisational outcomes with room service compared to a thaw‐retherm model in a large public hospital.
Pressure injuries (PI) are a significant clinical problem across all healthcare facilities, associated with poor patient outcomes, increased length of stay and healthcare costs. Whilst it is known ...that underweight (Body Mass Index (BMI) < 18.5 kg/m2) and malnourished individuals have an increased risk of developing PI, few studies have investigated the effects of obesity (BMI ≥ 30 kg/m2) and morbid obesity (BMI ≥ 40 kg/m2) on PI prevalence. This study aimed to determine whether PI prevalence was associated with levels of obesity; the complex association between morbid obesity, malnutrition and PI prevalence in hospital inpatients was also explored.
Data collected from annual Queensland Patient Safety Bedside Audits conducted between 2010 and 2015 was used to examine the outcomes of interest (n = 2479). Bivariate tests were used to explore relationships between age, gender, BMI, malnutrition and PI prevalence. Regression analysis explored associations between BMI, malnutrition and PI, adjusting for potential confounders.
Overall PI prevalence was 6.9% and was significantly higher in the underweight and morbidly obese groups (underweight 12.7%, healthy weight 7.8%, overweight 5.7%, obese 4.8%, morbidly obese 12%; p = 0.001). In addition to BMI, malnutrition and age were significantly associated with PI prevalence. After adjusting for confounders, morbidly obese inpatients had over three times the odds of developing a PI compared to healthy weight inpatients (OR = 3.478, 95% CI 1.657–7.303; p = 0.001). Morbidly obese inpatients who were also malnourished had eleven-fold greater odds of developing a PI compared to the morbidly obese well-nourished in logistic regression analysis (OR = 11.143, 95% CI 2.279–54.481, p = 0.003).
Morbid obesity is a significant and independent risk factor for PI development. However, the clustering of nutritional risk factors (morbid obesity and malnutrition) substantially increases this risk. Therefore, routine and formal assessment of both BMI and malnutrition status are important to enable the identification of patients at high risk of PI.
•Surgery for acute hip fracture in the elderly poses a very high mortality rate in a population that are usually highly multi-morbid.•While highlighting the importance of measuring comorbidity, ...international guidelines fail to suggest methods with which to do so.•The ASA remains a standard of use despite never being validated for this purpose.•The data suggests that the CCI is not a valid alternative to the ASA for the purposes of predicting 12-month mortality.
The ASA (American Society of Anaesthesiologists) Score is the current standard for measuring comorbidity in the Australian Hip Fracture registry, however it has never been validated for this purpose. Subsequently, a more appropriate and useful measure should be investigated. This study aimed to compare the ASA and Charlson Comorbidity Index (CCI) scores in predicting 12-month mortality following acute hip fracture.
A retrospective analysis was performed on an audit database of patients who were admitted to an orthogeriatric unit in a public metropolitan hospital from November 2010 to October 2011. 12-month mortality data was linked through a dual search of Queensland Health and mortality registry data. The Charlson comorbidity index was retrospectively applied. Demographics (age, gender, admission residence) and covariates including ASA, CCI, fracture type, fixation type, cognitive impairment on admission, BMI and time to surgery were analysed with logistic regression. ROC curve analysis was performed to assess varying thresholds for each comorbidity system.
A total of 320 patients were available for audit. Unadjusted bivariate analysis demonstrated significant difference between groups regarding increased age (p = 0.004), ASA score (p<0.001), CCI (p = 0.002), age-adjusted CCI (p = 0.002) and admission from a care facility (p<0.001). Logistic regression analysis demonstrated that only ASA (p<0.001) and admission from a care facility (p<0.001, OR=3.36, 95% CI = 1.9 - 6.0) independently predicted 12-month mortality; CCI was not a significant predictor in any models (p = 0.827, age-adjusted CCI: p = 0.864). Using ROC analysis, the ASA (AUC=0.668) outperformed either CCI (AUC=0.607 (CCI), AUC=0.614 (CCI age-adjusted).
The ASA score is independently associated with 12-month mortality; this was not replicated using either version of the CCI. The data does not suggest using the CCI in registry level datasets for the purposes of predicting 12-month mortality.
Many patients are admitted to hospital and are already malnourished. Gaps in practice have identified that care processes for these patients can be improved. Hospital staff, including management, ...needs to work towards optimizing nutrition care in hospitals to improve the prevention, detection and treatment of malnutrition. The objective of this study was to understand how staff members perceived and described the necessary ingredients to support change efforts required to improve nutrition care in their hospital.
A qualitative study was conducted using purposive sampling techniques to recruit participants for focus groups (FG) (n = 11) and key informant interviews (n = 40) with a variety of hospital staff and management. Discussions based on a semi-structured schedule were conducted at five diverse hospitals from four provinces in Canada as part of the More-2-Eat implementation project. One researcher conducted 2-day site visits over a two-month period to complete all interviews and FGs. Interviews were transcribed verbatim while key points and quotes were taken from FGs. Transcripts were coded line-by-line with initial thematic analysis completed by the primary author. Other authors (n = 3) confirmed the themes by reviewing a subset of transcripts and the draft themes. Themes were then refined and further detailed. Member checking of site summaries was completed with site champions.
Participants (n = 133) included nurses, physicians, food service workers, dietitians, and hospital management, among others. Discussion regarding ways to improve nutrition care in each specific site facilitated the thought process during FG and interviews. Five main themes were identified: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team.
Hospital staff need a reason to change their nutrition care practices and a significant change driver is perceived and experienced benefit to the patient. Participants described key ingredients to support successful change and specifically engaging the interdisciplinary team to effect sustainable improvements in nutrition care.
Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304 , June 7, 2016.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Introduction
Consensus has not been reached regarding ideal outcome measures for total hip arthroplasty (THA) clinical evaluation and research. The goal of this review was to analyze the trends in ...outcome metrics within the THA literature and to discuss the potential impact of instrument heterogeneity on clinical practice.
Materials and methods
A PubMed search of all manuscripts related to THA from January 2005 to December 2019 was performed. Statistical and linear regression analyses were performed for individual outcome metrics as a proportion of total THA publications over time.
Results
There was a statistically significant increase in studies utilizing outcomes metrics between 2005 and 2019 (15.1–29.5%;
P
< 0.001;
R
2
= 98.1%). Within the joint-specific subcategory, use of the Harris Hip Score (HHS) significantly decreased from 2005 to 2019 (82.8–57.3%;
P
< 0.001), use of the Hip Disability and Osteoarthritis Outcome Score (HOOS) significantly increased (0–6.7%;
P
< 0.001), and the modified HHS significantly increased (0–10.5%;
P
< 0.001). In the quality of life subcategory, EQ-5D demonstrated a significant increase in usage (0–34.8%;
P
< 0.001), while Short Form-36 significantly decreased (100% vs. 27.3%;
P
= 0.008).
Conclusions
The utilization of outcome-reporting metrics in THA has continued to increase, resulting in added complexity within the literature. The utilization rates of individual instruments have shifted over the past 15 years. Additional study is required to determine which specific instruments are recommended.
Summary Background & aims Malnutrition is highly prevalent and resistant to intervention following hip fracture. This study investigated the impact of individualised versus multidisciplinary ...nutritional care on nutrition intake and outcomes in patients admitted to a metropolitan hospital acute hip fracture unit. Methods A prospective, controlled before and after comparative interventional study aligning to the CONSORT guidelines for pragmatic clinical trials. Randomly selected patients receiving individualised nutritional care (baseline) were compared with post-interventional patients receiving a new model of nutritional care promoting nutrition as a medicine, multidisciplinary nutritional care, foodservice enhancements, and improved nutrition knowledge and awareness. Malnutrition was diagnosed using the Academy of Nutrition and Dietetics criteria. Results Fifty-eight weighed food records were available for each group across a total of 82 patients ( n = 44, n = 38). Group demographics were not significantly different with predominantly community dwelling (72%), elderly (82.2 years), female (70%), malnourished (51.0%) patients prone to co-morbidities (median 5) receiving early surgical intervention (median D1). Multidisciplinary nutritional care reduced intake barriers and increased total 24-h energy (6224 vs. 2957 kJ; p < 0.001) and protein (69.0 vs. 33.8 g; p < 0.001) intakes, reduced nutritional deterioration over admission (5.4 vs. 20.5%; p = 0.049), and increased discharge directly back to the community setting (48.0 vs. 17.6%; p = 0.012). Trends suggested a reduction in median length of stay (D13 vs. D14). Inpatient mortality remained low across groups (5.2%, 2.3%). Conclusions Multidisciplinary nutritional care improves nutrition intake and outcomes in acute hip fracture inpatients. Similar pragmatic study designs should be considered in other elderly inpatient populations perceived resistant to nutritional intervention.
Malnutrition risk is identified in over one-third of inpatients; reliance on dietetics-delivered nutrition care for all “at-risk” patients is unsustainable, inefficient, and ineffective. This study ...aimed to identify and prioritise low-value malnutrition care activities for de-implementation and articulate systematised interdisciplinary opportunities. Nine workshops, at eight purposively sampled hospitals, were undertaken using the nominal group technique. Participants were asked “What highly individualised malnutrition care activities do you think we could replace with systematised, interdisciplinary malnutrition care?” and “What systematised, interdisciplinary opportunities do you think we should do to provide more effective and efficient nutrition care in our ward/hospital?” Sixty-three participants were provided five votes per question. The most voted de-implementation activities were low-value nutrition reviews (32); education by dietitian (28); assessments by dietitian for patients with malnutrition screening tool score of two (22); assistants duplicating malnutrition screening (19); and comprehensive, individualised nutrition assessments where unlikely to add value (15). The top voted alternative opportunities were delegated/skill shared interventions (55), delegated/skill shared education (24), abbreviated malnutrition care processes where clinically appropriate (23), delegated/skill shared supportive food/fluids (14), and mealtime assistance (13). Findings highlight opportunities to de-implement perceived low-value malnutrition care activities and replace them with systems and skill shared alternatives across hospital settings.
Abstract
Background
Acute kidney injury (AKI) is a recognised complication of coronavirus disease 2019 (COVID-19), yet the reported incidence varies widely and the associated risk factors are poorly ...understood.
Methods
Data was collected on all adult patients who returned a positive COVID-19 swab while hospitalised at a large UK teaching hospital between 1st March 2020 and 3rd June 2020. Patients were stratified into community- and hospital-acquired AKI based on the timing of AKI onset.
Results
Out of the 448 eligible patients with COVID-19, 118 (26.3 %) recorded an AKI during their admission. Significant independent risk factors for community-acquired AKI were chronic kidney disease (CKD), diabetes, clinical frailty score and admission C-reactive protein (CRP), systolic blood pressure and respiratory rate. Similar risk factors were significant for hospital-acquired AKI including CKD and trough systolic blood pressure, peak heart rate, peak CRP and trough lymphocytes during admission. In addition, invasive mechanical ventilation was the most significant risk factor for hospital-acquired AKI (adjusted odds ratio 9.1, p < 0.0001) while atrial fibrillation conferred a protective effect (adjusted odds ratio 0.29, p < 0.0209). Mortality was significantly higher for patients who had an AKI compared to those who didn’t have an AKI (54.3 % vs. 29.4 % respectively, p < 0.0001). On Cox regression, hospital-acquired AKI was significantly associated with mortality (adjusted hazard ratio 4.64, p < 0.0001) while community-acquired AKI was not.
Conclusions
AKI occurred in over a quarter of our hospitalised COVID-19 patients. Community- and hospital-acquired AKI have many shared risk factors which appear to converge on a pre-renal mechanism of injury. Hospital- but not community acquired AKI was a significant risk factor for death.
Patient-reported outcome metrics and reporting are important for demonstrating value associated with total knee arthroplasty (TKA). This review studied the patient-reported outcome utilization trends ...as reported within the TKA literature over a 15-year period.
A PubMed search of all manuscripts related to TKA from January 2005 to December 2019 was performed. Descriptive statistics were used for individual outcome metrics as proportions of total article publications focusing on TKA outcomes. Linear regressions analysis was performed to demonstrate significant changes in utilization rates over time.
There was a significant overall increase in studies utilizing outcome metrics between 2005 and 2019 (16.1%-45.0%; P < .001; R2 = 98.7%). Within joint-specific metrics (2005-2019), use of Knee Disability and Osteoarthritis Outcome score increased (0%-14.8%; P < .001); while use of Knee Society Knee Scoring System decreased (55.2%-35.4%; P = .007). Of the studies reporting general health, use of the Forgotten Joint Score-12 decreased (100%-66.7% from 2014 to 2019; P = .006), and Patient-Reported Outcome Measurement Information System Global-10 increased (0%-21.4% from 2005 to 2019; P < .001). In the quality of life subcategory (2005-2019), EuroQol 5-Dimension Health Outcome Survey increased in usage (14.3%-28.0%; P < .001), while Short Form-36 use decreased (85.7%-36.6%; P < .001).
Although utilization of outcome metrics has significantly increased over the last 15 years in the TKA literature, there still exists considerable heterogeneity of outcome metrics. This lack of consensus may impede comparisons of studies for clinical and research purposes, as well as hinder cross-walk of outcome tools over time. Further study is needed to identify ideal global and joint-specific tools, while balancing issues like ease of use and utility in specific populations such as the young and highly active.
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