Oral corticosteroid stewardship: key insights from the Australasian Severe Asthma Registry.

BACKGROUND: People with severe asthma remain at risk of toxicity from maintenance oral corticosteroid (OCS) use and/or frequent OCS burst therapy. Cumulative exposures above 500-1000 mg prednisolone are associated with adverse effects, and recently OCS stewardship principles were promulgated to guide OCS prescription. AIMS: To examine real-world registry data to quantify OCS burden, ascertain trends over time in prescription and assess whether opportunities to implement steroid-sparing strategies were utilised. METHODS: Participants were enrolled in the Australasian Severe Asthma Registry for the period 2013-2021. Assessments were taken at enrolment and then annual follow-up, which included asthma control and OCS use. Descriptive analyses were performed, and subgroups were compared at baseline and over time. RESULTS: Nine hundred and twenty-four participants were evaluated and 215/924 (23%) were taking maintenance OCS at baseline, with 44% and 32% of participants having exposure to ≥500 or 1000 mg of OCS respectively in the prior year. Twelve months later, an additional 10% and 9% of participants reached cumulative doses of 500 or 1000 mg. People exceeding thresholds had ongoing poor asthma control. At baseline, 240/924 (26%) people were treated with asthma biological therapy. An additional 83 (12%) participants were identified as potentially benefiting from this steroid-sparing medication. Of these patients, only 23% commenced a biologic agent in the next 12 months. CONCLUSIONS: A large national asthma registry identifies exposure to toxic cumulative doses of OCS in more than a third of participants, with further subsequent cumulative dose escalation over 2 years. Steroid-sparing strategies were often not employed, highlighting the need for implementation of OCS stewardship initiatives.

Perioperative knowledge, self-efficacy and clinical practices related to postoperative delirium care in older people across geographical regions in Australia.

INTRODUCTION: In older people undergoing surgery, there is a lower tolerance for complications. This highlights the need for documented clinical practices on proper prevention, pre-screening and management of complications such as postoperative delirium (POD). Evidence-based clinical practice guidelines exist for delirium management; however, the management of delirium in clinical settings differs widely. OBJECTIVE: This study aims to develop an understanding of the knowledge, components of self-efficacy (confidence/competence), and clinical practice related to POD care among preoperative and recovery nurses across different types of geographical locations in Australia. DESIGN: A 27-item online survey was sent out to professional associations focused on perioperative care across Australia. The participants included practicing registered nurses specialising in perioperative care. The main outcome measures were Knowledge, confidence/competence and clinical practice relating to POD care in older patients. FINDINGS: Respondents were categorised into two groups-major cities and rural and remote. Mean age was 46.3 years for respondents in Australian major cities and 49.5 for the comparison group. There was a statistically significant difference between Australian major cities and 'rural and remote' in confidence in detecting hyperactive delirium, 25.2% versus 11.7% respectively as well as managing hyperactive delirium, 13.8% versus 1.7%, respectively. Similar results were also observed on hypoactive delirium. Respondents from both groups did not mirror the ideal situation in managing a hyperactive delirium. DISCUSSION: Results from this study are inconclusive and there is no clear-cut observation in clinical practice or knowledge between the two geographical categories in this study. CONCLUSION: The absence of a distinct strategy with POD prevention highlights the need for a uniform approach and consensus on POD prevention and management in older people. This can be achieved by creating more awareness and education through professional development related to POD.

Delirium education and post-anaesthetics care unit nurses' knowledge on recognising and managing delirium in older patients.

BACKGROUND: Postoperative delirium (POD) is a major complication following a surgical procedure. There is evidence that improving knowledge about POD could enhance POD care and patient outcomes. AIM: The study aimed to evaluate whether the amount of delirium education among registered nurses working in post-anaesthetics care units (PACU) impacts on their self-reported confidence and competence in recognising and managing delirium as well as prior knowledge on factors that influence the risk of delirium onset for older people. METHOD: The current study utilised an online survey on delirium care practice among registered nurses in PACUs. The survey consisted of 27 items. There were questions about confidence and competence in delirium care, knowledge about delirium risk factors, and ranked responses to two case scenario questions to evaluate the application of POD care. There were also demographic questions, including previous experience with delirium care education. RESULTS: A total of 336 responses were generated from registered nurses working in PACU. Our findings found substantial variability among the respondents about their delirium care education. The amount of delirium education did not influence the PACU registered nurses' confidence or competence in delirium care. In addition, previous education did not have an impact on their knowledge about delirium risk factors. DISCUSSION AND CONCLUSION: These findings suggested that the quantity of prior education about delirium did not improve the confidence, competence, knowledge, or case scenario questions of PACU registered nurses. Thus, delirium care education needs to be transformed to ensure it has a positive effect on delirium care clinical practice by registered nurses in PACU.

Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis.

BACKGROUND: With the increase in life expectancy around the globe, the incidence of postoperative delirium (POD) among older people (≥65 years) is growing. Previous studies showed a wide variation in the incidence of POD, from 4% to 53%, with a lack of specific evidence about the incidence of POD by specific surgery type among older people. The aim of this systematic review and meta-analysis was to determine the incidence of POD by surgery type within populations 65 years and over. METHODS: Databases including PubMed, Cochrane library, Embase, and CINAHL were searched until October 2020. Due to the relatively higher number of meta-analyses undertaken in this area of research, a streamlined systematic meta-analysis was proposed. RESULTS: A total of 28 meta-analyses (comprising 284 individual studies) were reviewed. Data from relevant individual studies (n = 90) were extracted and included in the current study. Studies were grouped into eight surgery types and the incidence of POD for orthopedic, vascular, spinal, cardiac, colorectal, abdominal, urologic, and mixed surgeries was 20%, 14%, 13%, 32%, 14%, 30%, 10%, and 26%, respectively. POD detection instruments were different across the studies, with Confusion Assessment Method (CAM & CAM-ICU) being the most frequently adopted. LINKING EVIDENCE TO ACTION: This study showed that POD incidence in older people undergoing surgery varied widely across surgery type. The more complex surgeries like cardiac and abdominal surgeries were associated with a higher risk of POD. This highlights the need to include the level of surgery complexity as a risk factor in preoperative assessments.

Postoperative Delirium in Older Patients: A Systematic Review of Assessment and Incidence of Postoperative Delirium.

BACKGROUND: Postoperative delirium is the most common complication of surgery particularly in older patients. AIMS: The current study aimed to summarize the commonly used delirium assessment tools in assessing postoperative delirium (POD) and to estimate the incidence rates of POD. METHODS: A systematic review that included empirical cohort studies reporting the use of delirium assessment tools in assessing POD between 2000 and 2019. Five core databases were searched for eligible studies. The methodological quality assessment of the included studies was undertaken using the Joanna Briggs Institute (JBI) critical appraisal checklist to examine the risk of bias. Pooled incidence estimates were calculated using a random effects model. RESULTS: Nineteen studies with a total of 3,533 postsurgery older patients were included in this review. The confusion assessment method (CAM) and CAM-ICU were the most commonly used tools to assess POD among older postoperative patients. The pooled incidence rate of POD was 24% (95% CI [0.20, 0.29]). The pooled incidence estimates for mixed (noncardiac) surgery, orthopedic surgery, and tumor surgery were 23% (95% CI [0.15, 0.31]), 27% (95% CI [0.20, 0.33]), and 19% (95% CI [0.15, 0.22]), respectively. More than 50% of included studies used CAM to assess POD in different types of postoperative patients. Using CAM to assess delirium is less time-consuming and it was suggested as the most efficient tool for POD detection. LINKING EVIDENCE TO ACTION: We identified that CAM could be implemented in different settings for assessing POD. The incidence and risk factors for POD introduced can be used for future research to target these potential indicators. The incidence rate, risk factors, and predictors of POD explored can provide robust evidence for clinical practitioners in their daily practice.

A Systematic Review on the Health Effects of Plums (Prunus domestica and Prunus salicina).

In recent times, plums have been described as foods with health-promoting properties. Research on the health effects of plum continue to show promising results on its antiinflammatory, antioxidant and memory-improving characteristics. The increased interest in plum research has been attributed to its high phenolic content, mostly the anthocyanins, which are known to be natural antioxidants. A systematic review of literature was carried out to summarize the available evidence on the impact of plums (Prunus species; domestica and salicina) on disease risk factors and health outcomes. A number of databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for relevant studies on plum health effects in vitro, animal studies and clinical trials. A total of 73 relevant peer-reviewed journal articles were included in this review. The level of evidence remains low. Of the 25 human studies, 6 were confirmatory studies of moderate quality, while 19 were exploratory. Plums have been shown to possess antioxidant and antiallergic properties, and consumption is associated with improved cognitive function, bone health parameters and cardiovascular risk factors. Most of the human trials used the dried version of plums rather than fresh fruit, thus limiting translation to dietary messages of the positioning of plums in a healthy diet. Evidence on the health effect of plums has not been extensively studied, and the available evidence needs further confirmation. Copyright © 2016 John Wiley & Sons, Ltd.

Retrospective study of COVID-19 outcomes among healthcare workers in Rivers State, Nigeria.

OBJECTIVE: To determine the illness severity and mortality among COVID-19-infected healthcare workers (HCWs). DESIGN: A retrospective cohort study using population-level data. Secondary analysis was conducted on collated data from the Public Health Emergency Operations Centre (PHEOC) at the State Ministry of Health, Rivers State, Nigeria. Data were gathered from the COVID-19 patient database of the PHEOC on demographics, place of work, illness severity and outcome. PARTICIPANTS: The cohort included all documented HCWs with confirmed COVID-19 infection (diagnosed by PCR). PRIMARY AND SECONDARY OUTCOME MEASURES: Illness severity defined as 'hospitalisation required' and treatment outcome labelled as 'alive' or 'dead' were the outcomes of interest. RESULTS: The mean age was 43 years and 50.5% of the cohort were female. Of the 301 HCWs infected, 187 patients were symptomatic with 32 requiring hospitalisation. Seven infected HCWs died of their COVID-19 infection, resulting in a case fatality ratio (CFR) of 2.3%. Population proportions for age groups, case presentation and mortality, would be significantly greater than those seen in the study population. Health professionals made up 79.7% (240) of the study cohort, with 68.8% (165) of them working at the teaching hospitals; the association between HCWs and health facilities they worked in, was significant. Symptomatic cases were more inclined to progress to severe illness ([Formula: see text] adjusted OR (aOR) 10.658, 95% CI 2.494 to 45.552); patients also had greater odds of dying from COVID-19 ([Formula: see text] aOR 1.079, 95% CI 1.02 to 1.141) per year increase in age adjusted for sex, case class and illness severity. CONCLUSIONS: Frontl-ine HCWs are at an increased risk of exposure to COVID-19 infections. In Nigeria, there is a higher risk of experiencing severe illness if symptomatic while infected with COVID-19. Preventive strategies, proper education and awareness must be put in place to protect HCWs. OBJECTIVE: To determine the illness severity and mortality among COVID-19-infected HCWs.

Is the Australian smoking population hardening?

BACKGROUND: The hardening hypothesis proposes that as smoking rates decline, the remaining smokers will become hardcore and resistant to quitting. This group of highly resistant quitters will potentially require more individualistic approaches to cessation and harm reduction. The harm reduction approach (specifically e-cigarettes) has been proposed as an option to address hardened Australian smokers. We tested the hardening hypothesis by analysing the rates of hardcore smoking in the Australian smoking population between 2010 and 2016. METHODS: Data were drawn from three waves of the National Drug Strategy Household Survey (NDSHS) in 2010, 2013 and 2016. Two different definitions were used to assess hardcore smoking to arrive at an upper and lower rate. Logistic regression models assessed hardcore smoker characteristics for both definitions of hardcore smoking. RESULTS: The most inclusive definition of hardcore smoking (i.e., a smoker with no plan to quit) showed a significant decline in hardcore smoking between 2010 and 2016 (5.49%-4.85%) In contrast, the prevalence of hardcore smoking using the most stringent definition (i.e., a current daily smoker of at least 15 cigarettes per day, aged 26 years or over, with no intention to quit, a lifetime consumption of at least 100 cigarettes, and no quit attempt in the past 12 months) did not change significantly between 2010 and 2016. CONCLUSION: The observed trends in the prevalence of hardcore smokers (i.e., either stable or declining depending on the definition) suggest that the Australian smoking population is not hardening. These results do not support claims that remaining smokers are becoming hardcore.

A survey about postoperative delirium in older patients among nurses and anaesthetists: implications for future practice and policy.

BACKGROUND: Postoperative delirium is a major complication associated with anaesthesia and surgery, more commonly seen in older people. AIMS: The aims of this study were to explore the knowledge and understanding of anaesthetists and nurses involved in anaesthesia through their responses to two case scenarios of postoperative delirium experienced by older people. METHODS: A 30-item online survey was sent to 500 potential respondents. RESULTS: Two hundred and twenty-six practitioners from Australia, New Zealand and Scotland responded. Most had no workplace protocols for anaesthesia planning in older people. There was substantial variability in practice in relation to postoperative delirium screening, detection, prevention and management. CONCLUSIONS: Improvements in education and awareness, together with a more coherent approach, for example, as recommended in the European Society of Anaesthesiology Guidelines, could help to reduce the impact of postoperative delirium in older people. This should be combined with ongoing research into perioperative optimisation of detection, prevention and management of postoperative delirium.

Multi-disciplinary and pharmacological interventions to reduce post-operative delirium in elderly patients: A systematic review and meta-analysis.

STUDY OBJECTIVE: An estimated 80% of older people undergoing surgery develop postoperative delirium (POD) making them a high-risk group. Research in this area is growing fast but there is no established consensus on strategies for POD prevention or management. A systematic review and meta-analysis were conducted to synthesise data on clinical interventions used to reduce POD among older people undergoing elective and emergency surgery. METHODS: A range of database searches generated 336 papers. A total of 25 studies met the inclusion criteria and were assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The studies were undertaken across the world. RESULTS: This review identified a range of intervention approaches: comparisons between anaesthetic and sedatives agents, medication-specific interventions and multidisciplinary models of care. Results found more consistencies across multidisciplinary interventions than the pharmacological interventions. In pooled analyses, haloperidol (OR 0.74; 95% CI (confidence interval) 0.44, 1.26) was not statistically significantly associated with reduced POD incidence any more than a placebo. CONCLUSION: There is a need to implement multidisciplinary interventions, as well as collaboration between clinicians on pre- and postoperative care practices regarding pharmacological interventions to more effectively reduce and manage POD in older people.

Low anthocyanin plum nectar does not impact cognition, blood pressure and gut microbiota in healthy older adults: A randomized crossover trial.

Queen Garnet plum (QGP), known for its high levels of anthocyanins, is a hybrid of the Japanese plum developed in Queensland, Australia. Anthocyanins provide the red, blue, and purple pigments in plants with demonstrated beneficial health effects. This study hypothesized that low-dose anthocyanin QGP intake will have a significant positive effect on cognition, blood pressure, and gut microbiota in healthy older adults. A randomized crossover trial was conducted to determine the effect and within subject variance on cognition and 24 hr. ambulatory blood pressure in older adults without cognitive impairment following daily consumption of 200 mL low-dose anthocyanin (5 mg/100 g) QGP nectar (intervention) or raspberry cordial (control). Secondary outcomes included inflammatory markers (C-reactive protein), nerve growth factor (BDNF), and gut microbiota (16S rRNA gene sequencing). Twenty-eight participants (55+ years) were recruited. Each randomized treatment arm lasted for 8 weeks with a 4-week washout period. Cognition, blood pressure, and urine samples were measured at each visit (5 total) while blood and fecal samples were collected at baseline, 8 weeks, and 20 weeks. Repeated-measures ANOVA was used to analyze the data. Across the treatments, no significant difference was observed for the different domains of cognition, blood pressure, or anti-inflammatory biomarkers. No intervention effect was found for genera or class of gut microbes. Low anthocyanin nectar derived from the QGP did not have any significant effects on cognition, blood pressure, or gut microbiota in healthy older adults.