Engaging stakeholders to level up COPD care in LMICs: lessons learned from the "Breathe Well" programme in Brazil, China, Georgia, and North Macedonia.

BACKGROUND: Effective stakeholder engagement in health research is increasingly being recognised and promoted as an important pathway to closing the gap between knowledge production and its use in health systems. However, little is known about its process and impacts, particularly in low-and middle-income countries. This opinion piece draws on the stakeholder engagement experiences from a global health research programme on Chronic Obstructive Pulmonary Disease (COPD) led by clinician researchers in Brazil, China, Georgia and North Macedonia, and presents the process, outcomes and lessons learned. MAIN BODY: Each country team was supported with an overarching engagement protocol and mentored to develop a tailored plan. Patient involvement in research was previously limited in all countries, requiring intensive efforts through personal communication, meetings, advisory groups and social media. Accredited training programmes were effective incentives for participation from healthcare providers; and aligning research findings with competing policy priorities enabled interest and dialogue with decision-makers. The COVID-19 pandemic severely limited possibilities for planned engagement, although remote methods were used where possible. Planned and persistent engagement contributed to shared knowledge and commitment to change, including raised patient and public awareness about COPD, improved skills and practice of healthcare providers, increased interest and support from clinical leaders, and dialogue for integrating COPD services into national policy and practice. CONCLUSION: Stakeholder engagement enabled relevant local actors to produce and utilise knowledge for small wins such as improving day-to-day practice and for long-term goals of equitable access to COPD care. For it to be successful and sustained, stakeholder engagement needs to be valued and integrated throughout the research and knowledge generation process, complete with dedicated resources, contextualised and flexible planning, and commitment.

Occurrence and predictors of delirium in critically ill older patients: a prospective cohort study.

Objectives: This study aims to analyze the occurrence of delirium in critically ill older patients and to identify predictors of delirium. Methods: This prospective study included critically ill older patients admitted into level II units of Intensive Care Medicine Department of a University Hospital. Patients with Glasgow Coma Scale score ≤11, traumatic brain injury, terminal disease, history of psychosis, blindness/deafness, or inability to understanding/speaking Portuguese were excluded. The Confusion Assessment Method-Short Form (CAM-4) was used to assess the presence of delirium. Results: The final sample (n = 105) had a median age of 80 years, most being female (56.2%), widowed (49.5%), and with complete primary education (53%). Through CAM-4, 36.2% of the patients had delirium. The delirium group was more likely to have previous cognitive decline (48.6% vs 19.6%, P = .04) and severe dependency in instrumental activities of daily living (34.3% vs 14.8%, P = .032), comparing with patients without delirium. The final multiple logistic regression model explained that patients with previous cognitive decline presented a higher risk for delirium (odds ratio: 4.663, 95% confidence Interval: 1.055-20.599, P = .042). Conclusions: These findings corroborate previous studies, showing that cognitive decline is an independent predictor for delirium in older patients. This study is an important contribution for the knowledge regarding the predictors of delirium. The recognition of these factors will help to identify patients who are at high risk for this syndrome and implement early screening and prevention strategies. However, further studies with larger samples, recruited from other clinical settings as well as analyzing other potential factors for delirium, will be needed.

Associations of medicine use and ejection fraction with the coexistence of frailty and sarcopenia in a sample of heart failure outpatients: a cross-sectional study.

BACKGROUND: Frailty and sarcopenia have been extensively studied in heart failure (HF) patients, but their coexistence is unknown. The aim of this work is to describe the coexistence of these conditions in a sample of HF outpatients and its association with the use of medication and left-ventricular ejection fraction. METHODS: Participants in this cross-sectional study were recruited from a HF outpatients' clinic in northern Portugal. Frailty phenotype was assessed according to Fried et al. Sarcopenia was evaluated according to the revised consensus of the European Working Group on Sarcopenia in Older People. RESULTS: A total of 136 HF outpatients (33.8% women, median age 59 years) integrated this study. Frailty and sarcopenia accounted for 15.4% and 18.4% of the sample, respectively. Coexistence of frailty and sarcopenia was found in 8.1% of the participants, while 17.6% had only one of the conditions. In multivariable analysis (n = 132), increasing age (OR = 1.13;95%CI = 1.06,1.20), being a woman (OR = 65.65;95%CI = 13.50, 319.15), having heart failure with preserved ejection fraction (HFpEF) (OR = 5.61; 95%CI = 1.22, 25.76), and using antidepressants (OR = 11.05; 95%CI = 2.50, 48.82), anticoagulants (OR = 6.11; 95%CI = 1.69, 22.07), furosemide (OR = 3.95; 95%CI = 1.07, 14.55), and acetylsalicylic acid (OR = 5.01; 95%CI = 1.10, 22.90) were associated with increased likelihood of having coexistence of frailty and sarcopenia, while using statins showed the inverse effect (OR = 0.06; 95%CI = 0.01, 0.30). CONCLUSIONS: The relatively low frequency of coexistence of frailty and sarcopenia signifies that each of these two conditions still deserve individual attention from health professionals in their clinical practice and should be screened separately. Being a woman, older age, having HFpEF, using anticoagulants, antidepressants, loop diuretics and acetylsalicylic acid, and not using statins, were associated with having concomitant frailty and sarcopenia. These patients can potentially benefit from interventions that impact their quality of life such as nutritional and mental health interventions and exercise training.

Strengthening the Diagnosis and Treatment of Malnutrition Through Increased Nurse Involvement: A Quality Improvement Project From Pediatric Wards in Mozambique.

BACKGROUND: Childhood acute malnutrition continues to be a serious health problem in many low-resource settings in Africa. On pediatric wards in Mozambique, missed opportunities for timely diagnosis and treatment of malnutrition may lead to poor health outcomes. To improve inpatient nutritional care, a quality improvement (QI) project was implemented that aimed to engage pediatric nurses in inpatient malnutrition diagnosis and treatment. METHODS: In 2 Mozambican referral hospitals, for 6 months, the Plan-Do-Study-Act framework for QI was implemented to identify key drivers of the following measures: having complete anthropometric evaluation documented at admission, 3 or more weight measurements per hospitalization week, documentation of nutritional therapy for eligible patients, and documentation of referral for outpatient nutritional rehabilitation after discharge. Clinical data were abstracted from hospital charts and entered into an EpiInfo database, including a 3-month observation period after the project, and analyzed retrospectively. RESULTS: A total of 2,208 children from wards other than malnutrition were included in the analysis. Complete anthropometric evaluation at admission improved from 24.4% 2 months before the QI project to 80.1% during and 75.2% in the 3 months after the project (P<.001). The percentage of patients with 3 or more weight measurements per hospitalization week rose from 22.3% to 82.8% during and 75.0% after the project (P<.001). Documentation of nutritional therapy increased from 58.8% before to 67.1% during and 70.6% after the project (P=.54), and documentation of referral for outpatient nutritional rehabilitation after discharge decreased from 55.9% to 54.9% during and increased to 70.6% after the project, (P<.001). CONCLUSION: Nurse engagement may lead to important advancements in the diagnosis and treatment of acute malnutrition in pediatric wards other than malnutrition in Mozambique. Task-sharing, particularly nurse engagement, in combination with QI methodology, may be considered for wards in similar settings with a high burden of malnutrition.

Randomised controlled trial testing effectiveness of feedback about lung age or exhaled CO combined with very brief advice for smoking cessation compared to very brief advice alone in North Macedonia: findings from the Breathe Well group.

INTRODUCTION: In 2019, smoking prevalence in North Macedonia was one of the world's highest at around 46% in adults. However, access to smoking cessation treatment is limited and no co-ordinated smoking cessation programmes are provided in primary care. METHODS: We conducted a three parallel-armed randomised controlled trial (n = 1368) to investigate effectiveness and cost-effectiveness of lung age (LA) or exhaled carbon monoxide (CO) feedback combined with very brief advice (VBA) to prompt smoking cessation compared with VBA alone, delivered by GPs in primary care in North Macedonia. All participants who decided to attempt to quit smoking were advised about accessing smoking cessation medications and were also offered behavioural support as part of the "ACT" component of VBA. Participants were aged ≥ 35 years, smoked ≥ 10 cigarettes per day, were recruited from 31 GP practices regardless of motivation to quit and were randomised (1:1:1) using a sequence generated before the start of recruitment. The primary outcome was biochemically validated 7-day point prevalence abstinence at 4 weeks (wks). Participants and GPs were not blinded to allocation after randomisation, however outcome assessors were blind to treatment allocation. RESULTS: There was no evidence of a difference in biochemically confirmed quitting between intervention and control at 4wks (VBA + LA RR 0.90 (97.5%CI: 0.35, 2.27); VBA + CO RR 1.04 (97.5%CI: 0.44, 2.44)), however the absolute number of quitters was small (VBA + LA 1.6%, VBA + CO 1.8%, VBA 1.8%). A similar lack of effect was observed at 12 and 26wks, apart from in the VBA + LA arm where the point estimate was significant but the confidence intervals were very wide. In both treatment arms, a larger proportion reported a reduction in cigarettes smoked per day at 4wks (VBA + LA 1.30 (1.10, 1.54); VBA + CO 1.23 (1.03, 1.49)) compared with VBA. The point estimates indicated a similar direction of effect at 12wks and 26wks, but differences were not statistically significant. Quantitative process measures indicated high fidelity to the intervention delivery protocols, but low uptake of behavioural and pharmacological support. VBA was the dominant intervention in the health economic analyses. CONCLUSION: Overall, there was no evidence that adding LA or CO to VBA increased quit rates. However, a small effect cannot be ruled out as the proportion quitting was low and therefore estimates were imprecise. There was some evidence that participants in the intervention arms were more likely to reduce the amount smoked, at least in the short term. More research is needed to find effective ways to support quitting in settings like North Macedonia where a strong smoking culture persists. TRIAL REGISTRATION: The trial was registered at http://www.isrctn.com (ISRCTN54228638) on the 07/09/2018.

Is Computed Tomography Necessary Before Septoplasty? Correlation With Physical Examination and Patient Complaints.

INTRODUCTION: Septoplasty is one of the most common surgeries performed by otorhinolaryngologists. The gold standard for the evaluation of septal deviation is anterior rhinoscopy and nasal endoscopy. Frequently, computed tomography (CT) is also performed, although the correlation between septal deviation on CT and physical examination is unclear. OBJECTIVES: To study the relationship between symptoms and physical and radiological evaluation in patients who underwent septoplasty. METHODS: A prospective study of patients with nasal obstruction and septal deviation who underwent septoplasty. Anterior rhinoscopy and nasal endoscopy were performed by the surgeon, and the CT was evaluated by a radiologist. The degree of obstruction was evaluated in three distinct septal locations. The Nasal Obstruction Symptom Evaluation (NOSE) score was used before the surgery and two months after the surgery. RESULTS: The study included 43 patients, of whom 60.5% were male, with an average age of 37.09 years (±12.56). The degree of septal deviation in the physical examination was significantly different from that observed in CT (p˂0.05). Cartilaginous or maxillary crest septal deviations >75% were more commonly recognized by physical examination, while osseous septum deviations of 25%-50% were more easily detected by CT. There was no difference between the degree of septal deviation and the preoperative NOSE. The median preoperative NOSE was 60, and the postoperative was 5, with significant improvement (p<0.05). CONCLUSION: CT doesn't appear to be useful in the evaluation of septal deviation since it is different from the findings of a physical examination and isn't associated with the NOSE score. Clinical decisions should be based on a physical examination and patient complaints.

Delirium related distress experienced by nurses / Distress nos enfermeiros relacionado com o Delirium / Distrés de los enfermeros relacionada con el Delirium

Abstract Background: Delirium is described as a distressful experience by patients and their families. Also, among healthcare staff, nurses caring for patients with delirium are the most at risk of high distress related to this syndrome. Aims: To assess nurses' distress related to delirium and its specific symptoms and severity. To identify factors nurses' sociodemographic and psychological characteristics and professional experience, that may be associated to this distress. Methods: A prospective study was carried out with nurses caring older adults with delirium in Intensive Care Medicine Service. Distress related to delirium, global psychological distress and burnout in nurses were measured with Delirium Experience Questionnaire, Kessler Psychological Distress Scale and Copenhagen Burnout Inventory, respectively. Results: Eighteen nurses were included (mean age=32 years; 89% women). About 46% of the nurses classified the experience of caring for patients in delirium as moderately distressing. Disorientation and psychomotor agitation were the most distressing symptoms. High distress related to delirium was associated with greater personal (p=0.040) and work-related burnout (p=0.020), and more global psychological distress (p=0.007). Conclusion: Caring for patients with delirium is distressing for nurses, particularly if the disorientation and psychomotor agitation are present and if nurses presented high burnout or psychological distress. This study highlights the need for development of education and support strategies for all professionals dealing with these patients.

Resumo Contexto: O delirium é descrito como uma experiência angustiante pelos pacientes e famílias. Também entre os profissionais de saúde, os enfermeiros que cuidam destes doentes são os que correm maior risco de grande distress relacionado com esta síndrome. Objetivos: Avaliar o distress dos enfermeiros relacionado com o delirium, os seus sintomas específicos e gravidade. Identificar fatores sociodemográficos e psicológicos e experiência profissional dos enfermeiros, que podem estar associados a este distress. Metodologia: Foi realizado um estudo prospetivo com enfermeiros que cuidam de idosos com delirium no Serviço de Medicina Intensiva. O distress relacionado com o delirium, distress psicológico global e burnout em enfermeiros foram medidos com Questionário Experiência de Delirium, Escala Distress Psicológico de Kessler e Inventário Burnout de Copenhaga, respetivamente. Resultados: Foram incluídos dezoito enfermeiros (média=32 anos; 89% mulheres). Cerca de 46% dos enfermeiros classificaram a experiência de cuidar de pacientes em delirium como moderadamente distressing. A desorientação e a agitação psicomotora, foram os sintomas mais distressing. O elevado distress relacionado com o delirium foi associado a um maior burnout pessoal (p=0,040) e relacionado com o trabalho (p=0,020), e mais distress psicológico global (p=0,007). Conclusões: Cuidar de doentes com delirium é distressing para os enfermeiros, particularmente se desorientação e agitação psicomotora estiverem presentes e se os enfermeiros apresentarem um elevado burnout ou distress psicológico. Este estudo salienta a necessidade do desenvolvimento de estratégias de formação e apoio para todos os profissionais que lidem com estes pacientes.

Resumen Antecedentes: Los pacientes y sus familias describen el delirium como una experiencia angustiosa. También entre los profesionales de la salud, los enfermeros que atienden a estos pacientes son las que corren más riesgo de sufrir un gran distrés relacionado con este síndrome. Objetivos: Evaluar el distrés de los enfermeros relacionada con el delirium, sus síntomas específicos y gravedad. Identificar los factores sociodemográficos y psicológicos de los enfermeros y experiencia profesional que pueden estar asociados a este distrés. Métodos: Se realizó un estudio prospectivo con los enfermeros que atendían a los pacientes ancianos con delirium en la Unidad de Cuidados Intensivos. Distrés relacionado con el delirium, distrés psicológico global y burnout en los enfermeros se midieron con Cuestionario Experiencia de Delirio, Escala Distrés Psicológico de Kessler y Inventario Burnout de Copenhague, respectivamente. Resultados: Se incluyeron dieciocho enfermeros (media=32 años;89% mujeres). Aproximadamente el 46% de los enfermeros calificaron la experiencia de atender a pacientes con delirium como moderadamente angustiosa. Desorientación y agitación psicomotriz fueron los síntomas con más distrés. Distrés relacionado con delirium se asoció con un mayor burnout personal (p=0,040) y laboral (p=0,020), y con más distrés psicológico global (p=0,007). Conclusión: El cuidado de los pacientes con delirium es angustioso para los enfermeros, en particular si hay desorientación y agitación psicomotriz y si los enfermeros tienen un alto grado de burnout o distrés psicológico. Este estudio pone de manifiesto la necesidad de desarrollar estrategias de formación y apoyo para todos los profesionales que tratan con estos pacientes.

Diferença entre os vocábulos bucal e oral na terminologia odontológica e seus significados na língua portuguesa / Difference between oral and oral vocables in dental terminology and their meanings in portuguese language

O objetivo do presente trabalho foi discutir sobre a diferença entre os termos bucal e oral na Odontologia, tendo como respaldo a Língua Portuguesa. A metodologia bibliográfica buscou se ancorar em teóricos da linguagem e da Odontologia para investigar a diferença entre tais palavras. Após leitura de textos que versaram sobre essas vertentes, observamos que a principal diferença residiu na origem das palavras bucca e os, originárias do latim clássico e vulgar, respectivamente, com significados distintos. Todavia, ao migrarem para o português, os falantes escolheram o termo bucca em detrimento de os, o qual ainda hoje é usado ao lado de oral, com sentidos semelhantes. Notamos, ainda, que para os profissionais da saúde seria importante padronizar a terminologia, pois facilitaria a compreensão desses termos para pacientes e profissionais de outras áreas, tais como os tradutores; por outro lado, ficou nítido que, em alguns momentos, a unificação terminológica seria mais difícil, pois os contextos de uso teriam que ser mudados. Por fim, destacamos que estudar estes vocábulos no contexto da Odontologia é importante para que tanto pacientes quanto os profissionais de saúde, ou de áreas similares conheçam a peculiar diferença(AU)

The objective of the present work was to discuss the difference between the terms oral and oral in Dentistry, based on the Portuguese language. The bibliographic methodology sought to anchor in language and dentistry theorists to investigate the difference between such words. After reading texts that dealt with these aspects, we observed that the main difference resided in the origin of the word bucca and os, originating from classical and vulgar Latin, respectively, with different meanings. However, when migrating to Portuguese, the speakers chose the term bucca over os, which is still used alongside oral, with similar meanings. We also noted that for health professionals it would be important to standardize the terminology, as it would facilitate the understanding of these terms for patients and professionals from other areas, such as translators; on the other hand, it was clear that at times, terminological unification would be more difficult, as the contexts of use would have to be changed. Finally, we emphasize that studying these words in the context of Dentistry is important so that both patients and health professionals, or from similar areas, know the peculiar difference(AU)

Frailty phenotype in heart failure: A condition that transcends age.

INTRODUCTION AND OBJECTIVES: Studies on younger frail and pre-frail subjects suffering from heart failure (HF) are scarce, except for those focusing on the critically ill. This work aims to describe differences between younger (<65 years) and older (≥65 years) pre-frail and frail HF outpatients regarding their nutritional, functional and clinical statuses. METHODS: In this cross-sectional study, a sample of 99 HF frail and pre-frail patients (aged 24-81 years, 38.4% women, 21.2% frail, 59.6% <65 years) was recruited from an HF outpatients' clinic in northern Portugal. Muscle mass was estimated from mid-upper arm muscle circumference. Weight status was assessed using body mass index. Hand grip strength and gait speed were measured. Medical records were reviewed. Associations between participants' characteristics and age were calculated using binary logistic regression. RESULTS: Age was associated with hand grip strength (OR=0.90), gait speed (OR=0.01) and diabetes (OR=4.95). Obesity, muscle mass or heart failure functional classes were not associated with age categories. CONCLUSION: There is an overall lack of differentiation between younger and older HF patients with the frailty phenotype. Therefore, frailty phenotype should be assessed in all patients, regardless of age. Hand grip strength seems to be a good predictor for older age and more studies are needed to define age-specific hand grip strength cut-offs for HF populations.

Remote consultations in primary care across low-, middle- and high-income countries: Implications for policy and care delivery.

The COVID-19 pandemic mandated a substantial switch in primary health care delivery from an in-person to a mainly remote telephone or video service. As the COVID-19 pandemic approaches its third year, limited progress appears to have been made in terms of policy development around consultation methods for the post-acute phase of the pandemic. In September 2020, the International Primary Care Respiratory Group convened a global panel of primary care clinicians - including family physicians, paediatricians, pharmacists, academics and patients - to consider the policy and health management implications of the move to remote consultations in the primary care setting. The group gave special consideration to how and how far remote consultations should be integrated into routine primary health care delivery. Remote consultations can be a useful alternative to in-person consultations in primary care not only in situations where there is a need for viral infection control but also for the routine delivery of chronic disease management. However, they may not be more time efficient for the clinician, and they can add to the workload and work-related stress for primary care practitioners if they remain the dominant consultation mode. Remote consultations are also less appropriate than in-person consultations for new disease diagnosis, dealing with multiple issues and providing complex care. Ensuring health care professionals have the appropriate skill set to effectively deliver remote consultations, administrative and/or IT support and appropriate reimbursement will be key to achieving optimal integration of remote consultations into routine clinical practice. Addressing digital access and digital literacy issues at a societal level will also be essential to ensure individuals have fair and equitable access to the internet and sufficient security for exchange of personal and health-related data.

Rapid neurodevelopmental recovery after ART initiation in an infant with HIV encephalopathy.

While there is ample evidence that antiretroviral therapy (ART) can improve cognitive outcomes in older children living with HIV, encephalopathy in infants has historically been considered an advanced disease presentation with less likelihood of neurodevelopmental recovery on treatment. More recent studies suggest that timely ART can halt encephalopathic disease progression and even lead to symptom resolution. Here we present a case of an HIV-positive infant diagnosed with encephalopathy who experienced impressive and rapid improvement with a multi-disciplinary care approach that included physical and occupational therapy and ART.

Protective Responses at the Biochemical and Molecular Level Differ between a Coffea arabica L. Hybrid and Its Parental Genotypes to Supra-Optimal Temperatures and Elevated Air [CO2].

Climate changes with global warming associated with rising atmospheric [CO2] can strongly impact crop performance, including coffee, which is one of the most world's traded agricultural commodities. Therefore, it is of utmost importance to understand the mechanisms of heat tolerance and the potential role of elevated air CO2 (eCO2) in the coffee plant response, particularly regarding the antioxidant and other protective mechanisms, which are crucial for coffee plant acclimation. For that, plants of Coffea arabica cv. Geisha 3, cv. Marsellesa and their hybrid (Geisha 3 × Marsellesa) were grown for 2 years at 25/20 °C (day/night), under 400 (ambient CO2, aCO2) or 700 µL (elevated CO2, eCO2) CO2 L-1, and then gradually submitted to a temperature increase up to 42/30 °C, followed by recovery periods of 4 (Rec4) and 14 days (Rec14). Heat (37/28 °C and/or 42/30 °C) was the major driver of the response of the studied protective molecules and associated genes in all genotypes. That was the case for carotenoids (mostly neoxanthin and lutein), but the maximal (α + ß) carotenes pool was found at 37/28 °C only in Marsellesa. All genes (except VDE) encoding for antioxidative enzymes (catalase, CAT; superoxide dismutases, CuSODs; ascorbate peroxidases, APX) or other protective proteins (HSP70, ELIP, Chape20, Chape60) were strongly up-regulated at 37/28 °C, and, especially, at 42/30 °C, in all genotypes, but with maximal transcription in Hybrid plants. Accordingly, heat greatly stimulated the activity of APX and CAT (all genotypes) and glutathione reductase (Geisha3, Hybrid) but not of SOD. Notably, CAT activity increased even at 42/30 °C, concomitantly with a strongly declined APX activity. Therefore, increased thermotolerance might arise through the reinforcement of some ROS-scavenging enzymes and other protective molecules (HSP70, ELIP, Chape20, Chape60). Plants showed low responsiveness to single eCO2 under unstressed conditions, while heat promoted changes in aCO2 plants. Only eCO2 Marsellesa plants showed greater contents of lutein, the pool of the xanthophyll cycle components (V + A + Z), and ß-carotene, compared to aCO2 plants at 42/30 °C. This, together with a lower CAT activity, suggests a lower presence of H2O2, likely also associated with the higher photochemical use of energy under eCO2. An incomplete heat stress recovery seemed evident, especially in aCO2 plants, as judged by the maintenance of the greater expression of all genes in all genotypes and increased levels of zeaxanthin (Marsellesa and Hybrid) relative to their initial controls. Altogether, heat was the main response driver of the addressed protective molecules and genes, whereas eCO2 usually attenuated the heat response and promoted a better recovery. Hybrid plants showed stronger gene expression responses, especially at the highest temperature, when compared to their parental genotypes, but altogether, Marsellesa showed a greater acclimation potential. The reinforcement of antioxidative and other protective molecules are, therefore, useful biomarkers to be included in breeding and selection programs to obtain coffee genotypes to thrive under global warming conditions, thus contributing to improved crop sustainability.

Frailty in Portuguese Older Patients From Convalescence Units: A Cross-Sectional Study.

Background: Frailty is a common geriatric syndrome, associated with adverse clinical outcomes. Nevertheless, studies about frailty in continuous care units are scarce. In this way, this study aimed to assess frailty in older patients admitted in convalescence units (CUs) and analyze its association with demographic, social and clinical characteristics. Methods: This cross-sectional study included older patients admitted in eight CUs of the Integrated Continued Care National Network in Northern Portugal. Exclusion criteria were: total ≤ 11 in Glasgow coma scale, < 10 in mini-mental state examination or being unable to communicate. A comprehensive protocol was administered to assess health-related and lifestyle characteristics, comorbidity, dependence on activities of daily living (ADL), depressive and anxiety symptoms, cognition, and socio-familial risk. Frailty was assessed by Tilburg frailty indicator (TFI). Results: A sample of 165 patients was included (median age = 77; 65% female), with 80% classified as frail, mostly women (P = 0.002), widowed (P = 0.016), shorter (P = 0.005), feeling more tired (P < 0.005) and with less energy (P < 0.005). Also, these patients reported more vision problems (P = 0.006), difficulties in walking (P = 0.022) and climbing stairs (P = 0.029), pain (P = 0.004), falls (P = 0.046), non-alcohol use (P = 0.043) and non-physical activity (P = 0.032). Frail patients had a higher number of previous hospitalizations (P = 0.018), comorbidity (P = 0.006), dependence on instrumental (P < 0.001) and basic (P = 0.006; P < 0.001) ADL, depressive (P < 0.001) and anxiety (P = 0.002) symptoms. After adjusting for covariates, frailty was associated with females (adjusted odds ratio (aOR) = 4.45, P = 0.011), vascular disease (aOR = 4.40, P = 0.040), vision problems (aOR = 10.85, P < 0.001), high dependency on instrumental ADL (aOR = 0.74, P = 0.002), and depressive symptoms (aOR = 1.37, P = 0.001). Conclusions: Frailty is high among older patients in CUs, particularly in females, with vascular disease, vision problems, instrumental ADL dependence and depressive symptoms. Thus, frailty should be screened, and preventive and therapeutic measures should be considered for those at high risk, in order to minimize possible negative consequences.

Anxiety in heart failure patients and its association with socio-demographic and clinical characteristics: a cross-sectional study.

Anxiety is one of the most frequent psychiatric disorders in heart failure (HF) patients. However, it is often neglected in clinical practice and studies about the particular relationship with the New York Heart Association (NYHA) classes for HF are scarce. In this context, this study aims to analyze the presence of anxiety symptoms in HF outpatients and also its association with sociodemographic and clinical characteristics of these patients. Methods: This cross-sectional study is part of the longitudinal Deus Ex-Machina project (NORTE-01-0145-FEDER-000026). HF patients were recruited at an outpatient clinic at a University Hospital. Patients with inability to communicate, severe visual/hearing impairment, or NYHA class IV were excluded. Sociodemographic data and NYHA class were registered. Anxiety was assessed with the 7-item Generalized Anxiety Disorders Scale (with a score ≥10 clinically relevant anxiety). Patients with and without anxiety were compared regarding socio-demographic and clinical variables. Results: The sample (n = 136) had a median age of 59years (Q1: 49; Q3: 68), 66.2% were male and 31.6% presented clinically relevant anxiety. A higher percentage of HF patients with anxiety had psychiatric disorders (58.1% vs 26.9%; P = .001), psychotropic medication (62.8% vs 30.1%; P = .001), and depression (60.5% vs 9.7%; P< .001). No significant differences were found regarding the remaining variables, including NYHA classes. Conclusions: A substantial proportion of HF patients present clinically relevant anxiety, particularly those with psychiatric history, depressive symptoms, or under psychotropic medication. Therefore, integrating routine screening and treatment of this comorbidity in clinical practice is of utmost importance. Further studies are needed to clarify the association of anxiety with HF.

Feasibility of a pulmonary rehabilitation programme for patients with symptomatic chronic obstructive pulmonary disease in Georgia: a single-site, randomised controlled trial from the Breathe Well Group.

OBJECTIVES: To assess the feasibility of delivering a culturally tailored pulmonary rehabilitation (PR) programme and conducting a definitive randomised controlled trial (RCT). DESIGN: A two-arm, randomised feasibility trial with a mixed-methods process evaluation. SETTING: Secondary care setting in Georgia, Europe. PARTICIPANTS: People with symptomatic spirometry-confirmed chronic obstructive pulmonary disease recruited from primary and secondary care. INTERVENTIONS: Participants were randomised in a 1:1 ratio to a control group or intervention comprising 16 twice-weekly group PR sessions tailored to the Georgian setting. PRIMARY AND SECONDARY OUTCOME MEASURES: Feasibility of the intervention and RCT were assessed according to: study recruitment, consent and follow-up, intervention fidelity, adherence and acceptability, using questionnaires and measurements at baseline, programme end and 6 months, and through qualitative interviews. RESULTS: The study recruited 60 participants (as planned): 54 (90%) were male, 10 (17%) had a forced expiratory volume in 1 second of ≤50% predicted. The mean MRC Dyspnoea Score was 3.3 (SD 0.5), and mean St George's Respiratory Questionnaire (SGRQ) 50.9 (SD 17.6). The rehabilitation specialists delivered the PR with fidelity. Thirteen (43.0%) participants attended at least 75% of the 16 planned sessions. Participants and rehabilitation specialists in the qualitative interviews reported that the programme was acceptable, but dropout rates were high in participants who lived outside Tbilisi and had to travel large distances. Outcome data were collected on 63.3% participants at 8 weeks and 88.0% participants at 6 months. Mean change in SGRQ total was -24.9 (95% CI -40.3 to -9.6) at programme end and -4.4 (95% CI -12.3 to 3.4) at 6 months follow-up for the intervention group and -0.5 (95% CI -8.1 to 7.0) and -8.1 (95% CI -16.5 to 0.3) for the usual care group at programme end and 6 months, respectively. CONCLUSIONS: It was feasible to deliver the tailored PR intervention. Approaches to improve uptake and adherence warrant further research. TRIAL REGISTRATION NUMBER: ISRCTN16184185.

Comprehensive geriatric assessment of older patients and associated factors of admission to Emergency Departments in pre-covid 19 Era - A Portuguese study.

OBJECTIVES: Identifying frequent users' (≥3admissions/year) associated factors in an emergency department (ED), using a comprehensive geriatric assessment (CGA), describing the characteristics of patients over 65 years of age. METHODS: A cross-sectional study was performed between August 2017 and June 2018 in an ED in Lisbon, Portugal. CGA was applied and completed with clinical records. Clinical, functional, mental and social scores were created based in Portuguese Society of Internal Medicine, and a statistical model was developed. RESULTS: CGA was applied to 426 patients over 64 years old in an ED. The mean age was 79.3, 84.7% had multimorbidity. 51.2%, 75.6%, and 40% had dependence on basic, instrumental, and walking activities, respectively. 52% had depressive symptoms, 65.7% had cognitive impairment, 63% were undernourished/at risk for malnutrition. 33.1% were socially at risk. Polypharmacy was present with a use on average of 6.5 drugs daily. Social, clinical, functional, and mental scores were unfavourable in 48.6%, 79.6%, 54.9% and 83.1% of the population, respectively. There were 2.7 hospital admissions/year and 39.9% were frequent ED users (≥3/year). The logistic regression model was weak, but showed that patients with polypharmacy, elevated Charlson Comorbidity index and an impairment nutritional status presented higher risk of being frequent users. CONCLUSIONS: This study showed that 97.1% of patients had needs that would justify an interventional care plan. This intervention should be extended to primary care and nursing homes. While not providing a robust model, our study has indicated nutritional problems, polypharmacy, and an elevated Charlson index as the features with more weight in frequent users' admissions.

High-resolution shotgun proteomics reveals that increased air [CO2] amplifies the acclimation response of coffea species to drought regarding antioxidative, energy, sugar, and lipid dynamics.

As drought threatens crop productivity it is crucial to characterize the defense mechanisms against water deficit and unveil their interaction with the expected rise in the air [CO2]. For that, plants of Coffea canephora cv. Conilon Clone 153 (CL153) and C. arabica cv. Icatu grown under 380 (aCO2) or 700 µL L-1 (eCO2) were exposed to moderate (MWD) and severe (SWD) water deficits. Responses were characterized through the activity and/or abundance of a selected set of proteins associated with antioxidative (e.g., Violaxanthin de-epoxidase, Superoxide dismutase, Ascorbate peroxidases, Monodehydroascorbate reductase), energy/sugar (e.g., Ferredoxin-NADP reductase, NADP-dependent glyceraldehyde-3-phosphate dehydrogenase, sucrose synthase, mannose-6-phosphate isomerase, Enolase), and lipid (Lineolate 13S-lipoxygenase) processes, as well as with other antioxidative (ascorbate) and protective (HSP70) molecules. MWD caused small changes in both genotypes regardless of [CO2] level while under the single imposition to SWD, only Icatu showed a global reinforcement of most studied proteins supporting its tolerance to drought. eCO2 alone did not promote remarkable changes but strengthened a robust multi-response under SWD, even supporting the reversion of impacts already observed by CL153 at aCO2. In the context of climate changes where water constraints and [CO2] levels are expected to increase, these results highlight why eCO2 might have an important role in improving drought tolerance in Coffea species.

Depressive and Anxiety Symptoms in Severe COVID-19 Survivors: A Prospective Cohort Study.

The coronavirus disease 2019 (COVID-19) has rapidly spread worldwide, leading to increased concerns about long-term patients' neuropsychiatric consequences. This study aims to describe the presence of depressive and anxiety symptoms in severe COVID-19 survivors and to identify associated baseline, in-hospital and post-discharge factors. This study is part of the MAPA longitudinal project conducted with severe COVID-19 patients admitted in Intensive Care Medicine Department (ICMD) of a University Hospital (CHUSJ) in Porto, Portugal. Patients with ICMD length of stay ≤ 24 h, terminal illness, major auditory loss or inability to communicate at follow-up assessment were excluded. All participants were assessed by telephone post-discharge (median = 101 days), with a comprehensive protocol assessing depressive and anxiety symptoms, cognition, Intensive Care Unit (ICU) memories recall and health-related quality of life. Out of a sample of 56 survivors (median age = 65; 68% males), 29% and 23% had depressive and anxiety symptoms, respectively. Depressive and anxiety symptoms were significantly more prevalent among younger survivors and were associated with cognitive complaints, emotional and delusions ICU memories and fear of having COVID-19 sequelae, sleep problems and pain after discharge (all p < 0.05). An important proportion of these survivors suffers from depression and anxiety symptoms post-discharge, namely younger ones and those who reported more cognitive complaints, ICU memories, fear of having COVID-19 sequelae, sleep problems and pain. These findings highlight the importance of psychological consequences assessment and planning of appropriate and multidisciplinary follow-up care after hospitalization due to COVID-19.

Community lung health service design for COPD patients in China by the Breathe Well group.

COPD is increasingly common in China but is poorly understood by patients, medications are not used as prescribed and there is no access to recommended non-pharmacological treatment. We explored COPD patients' and general practitioners' (GPs) knowledge of COPD, views on its management and the acceptability of a flexible lung health service (LHS) offering health education, exercise, self-management, smoking cessation and mental health support. Using a convergent mixed methods design, data were collected from patients and GPs using focus groups (FGs) in four Chinese cities, questionnaires were also used to collect data from patients. FGs were audio-recorded and transcribed. Quantitative data were analysed descriptively, thematic framework analysis was used for the qualitative data. Two-hundred fifty-one patients completed the questionnaire; 39 patients and 30 GPs participated in ten separate FGs. Three overarching themes were identified: patients' lack of knowledge/understanding of COPD, current management of COPD not meeting patients' needs and LHS design, which was well received by patients and GPs. Participants wanted COPD education, TaiChi, psychological support and WeChat for social support. 39% of survey responders did not know what to do when their breathing worsened and 24% did not know how to use their inhalers. 36% of survey respondents requested guided relaxation. Overall, participants did not fully understand the implications of COPD and current treatment was sub-optimal. There was support for developing a culturally appropriate intervention meeting Chinese patients' needs, health beliefs, and local healthcare delivery. Further research should explore the feasibility of such a service.

Frailty syndrome among older adults after hospitalization: A structural equation modeling analysis.

AIM: To analyze the association of demographic, clinical, health and functional capacity variables as predictors of frailty in older adults after one year of hospital discharge. BACKGROUND: There is still insufficient research with older persons after hospital discharge that evaluated the predictive variables for an increase in the frailty score. Identifying the characteristics that result in greater risk helps to guide care and interventions. METHODS: Longitudinal study involving 129 older adults who completed the follow-up. The Frailty Phenotype was used according to Fried and sociodemographic, clinical, health and functional capacity variables. Analysis was performed using structural equation modeling. RESULTS: At admission, the highest percentage (53.4%) of older adults were pre-frail, followed by frail (23.3%) and non-frail (23.3%). After a year of discharge, there was a decrease in the frail condition (22.5%) and pre-frail (52.7%); and an increase in non-frail (24.8%). At baseline, 29.5% showed impairment in only one component, with an increase in the percentage at follow-up (37.2%). The highest number of morbidities and hospital readmissions and lower IADL scores were predictors of an increase in the frailty score during follow-up. CONCLUSION: The prevalence of frailty was high among hospitalized older adults and after follow-up. Identifying the risk factors allows early and individualized interventions with reduction of negative outcomes. During hospitalization, a multidimensional assessment of older adults should be performed, especially with regard to frailty. The recognition of frailty predictors directs the care of older persons considering their individual needs and allows the improvement and/or stability of the frailty condition.