NSAID use and clinical outcomes in COVID-19 patients: a 38-center retrospective cohort study.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to reduce pain, fever, and inflammation but have been associated with complications in community-acquired pneumonia. Observations shortly after the start of the COVID-19 pandemic in 2020 suggested that ibuprofen was associated with an increased risk of adverse events in COVID-19 patients, but subsequent observational studies failed to demonstrate increased risk and in one case showed reduced risk associated with NSAID use. METHODS: A 38-center retrospective cohort study was performed that leveraged the harmonized, high-granularity electronic health record data of the National COVID Cohort Collaborative. A propensity-matched cohort of 19,746 COVID-19 inpatients was constructed by matching cases (treated with NSAIDs at the time of admission) and 19,746 controls (not treated) from 857,061 patients with COVID-19 available for analysis. The primary outcome of interest was COVID-19 severity in hospitalized patients, which was classified as: moderate, severe, or mortality/hospice. Secondary outcomes were acute kidney injury (AKI), extracorporeal membrane oxygenation (ECMO), invasive ventilation, and all-cause mortality at any time following COVID-19 diagnosis. RESULTS: Logistic regression showed that NSAID use was not associated with increased COVID-19 severity (OR: 0.57 95% CI: 0.53-0.61). Analysis of secondary outcomes using logistic regression showed that NSAID use was not associated with increased risk of all-cause mortality (OR 0.51 95% CI: 0.47-0.56), invasive ventilation (OR: 0.59 95% CI: 0.55-0.64), AKI (OR: 0.67 95% CI: 0.63-0.72), or ECMO (OR: 0.51 95% CI: 0.36-0.7). In contrast, the odds ratios indicate reduced risk of these outcomes, but our quantitative bias analysis showed E-values of between 1.9 and 3.3 for these associations, indicating that comparatively weak or moderate confounder associations could explain away the observed associations. CONCLUSIONS: Study interpretation is limited by the observational design. Recording of NSAID use may have been incomplete. Our study demonstrates that NSAID use is not associated with increased COVID-19 severity, all-cause mortality, invasive ventilation, AKI, or ECMO in COVID-19 inpatients. A conservative interpretation in light of the quantitative bias analysis is that there is no evidence that NSAID use is associated with risk of increased severity or the other measured outcomes. Our results confirm and extend analogous findings in previous observational studies using a large cohort of patients drawn from 38 centers in a nationally representative multicenter database.

Muscle Protein Anabolic Resistance to Essential Amino Acids Does Not Occur in Healthy Older Adults Before or After Resistance Exercise Training.

Background: The muscle protein anabolic response to contraction and feeding may be blunted in older adults. Acute bouts of exercise can improve the ability of amino acids to stimulate muscle protein synthesis (MPS) by activating mechanistic target of rapamycin complex 1 (mTORC1) signaling, but it is not known whether exercise training may improve muscle sensitivity to amino acid availability. Objective: The aim of this study was to determine if muscle protein anabolism is resistant to essential amino acids (EAAs) and whether resistance exercise training (RET) improves muscle sensitivity to EAA in healthy older adults. Methods: In a longitudinal study, 19 healthy older adults [mean ± SD age: 71 ± 4 y body mass index (kg/m2): 28 ± 3] were trained for 12 wk with a whole-body program of progressive RET (60-75% 1-repetition maximum). Body composition, strength, and metabolic health were measured pre- and posttraining. We also performed stable isotope infusion experiments with muscle biopsies pre- and posttraining to measure MPS and markers of amino acid sensing in the basal state and in response to 6.8 g of EAA ingestion. Results: RET increased muscle strength by 16%, lean mass by 2%, and muscle cross-sectional area by 27% in healthy older adults (P < 0.05). MPS and mTORC1 signaling (i.e., phosphorylation status of protein kinase B, 4E binding protein 1, 70-kDa S6 protein kinase, and ribosomal protein S6) increased after EAA ingestion (P < 0.05) pre- and posttraining. RET increased basal MPS by 36% (P < 0.05); however, RET did not affect the response of MPS and mTORC1 signaling to EAA ingestion. Conclusion: RET increases strength and basal MPS, promoting hypertrophy in healthy older adults. In these subjects, a small dose of EAAs stimulates muscle mTORC1 signaling and MPS, and this response to EAAs does not improve after RET. Our data indicate that anabolic resistance to amino acids may not be a problem in healthy older adults. This trial was registered at www.clinicaltrials.gov as NCT02999802.

Effect of Home- and Community-Based Physical Activity Interventions on Physical Function Among Cancer Survivors: A Systematic Review and Meta-Analysis.

OBJECTIVE: To examine the effect of home- and community-based physical activity interventions on physical functioning among cancer survivors based on the most prevalent physical function measures, randomized trials were reviewed. DATA SOURCES: Five electronic databases-Medline Ovid, PubMed, CINAHL, Web of Science, and PsycINFO-were searched from inception to March 2016 for relevant articles. STUDY SELECTION: Search terms included community-based interventions, physical functioning, and cancer survivors. A reference librarian trained in systematic reviews conducted the final search. DATA EXTRACTION: Four reviewers evaluated eligibility and 2 reviewers evaluated methodological quality. Data were abstracted from studies that used the most prevalent physical function measurement tools-Medical Outcomes Study 36-Item Short-Form Health Survey, Late-Life Function and Disability Instrument, European Organisation for the Research and Treatment of Cancer Quality-of-Life Questionnaire, and 6-minute walk test. Random- or fixed-effects models were conducted to obtain overall effect size per physical function measure. DATA SYNTHESIS: Fourteen studies met inclusion criteria and were used to compute standardized mean differences using the inverse variance statistical method. The median sample size was 83 participants. Most of the studies (n=7) were conducted among breast cancer survivors. The interventions produced short-term positive effects on physical functioning, with overall effect sizes ranging from small (.17; 95% confidence interval [CI], .07-.27) to medium (.45; 95% CI, .23-.67). Community-based interventions that met in groups and used behavioral change strategies produced the largest effect sizes. CONCLUSIONS: Home and community-based physical activity interventions may be a potential tool to combat functional deterioration among aging cancer survivors. More studies are needed among other cancer types using clinically relevant objective functional measures (eg, gait speed) to accelerate translation into the community and clinical practice.

Post-absorptive muscle protein turnover affects resistance training hypertrophy.

PURPOSE: Acute bouts of resistance exercise and subsequent training alters protein turnover in skeletal muscle. The mechanisms responsible for the changes in basal post-absorptive protein turnover and its impact on muscle hypertrophy following resistance exercise training are unknown. Our goal was to determine whether post-absorptive muscle protein turnover following 12 weeks of resistance exercise training (RET) plays a role in muscle hypertrophy. In addition, we were interested in determining potential molecular mechanisms responsible for altering post-training muscle protein turnover. METHODS: Healthy young men (n = 31) participated in supervised whole body progressive RET at 60-80% 1 repetition maximum (1-RM), 3 days/week for 3 months. Pre- and post-training vastus lateralis muscle biopsies and blood samples taken during an infusion of 13C6 and 15N phenylalanine and were used to assess skeletal muscle protein turnover in the post-absorptive state. Lean body mass (LBM), muscle strength (determined by dynamometry), vastus lateralis muscle thickness (MT), myofiber type-specific cross-sectional area (CSA), and mRNA were assessed pre- and post-RET. RESULTS: RET increased strength (12-40%), LBM (~5%), MT (~15%) and myofiber CSA (~20%) (p < 0.05). Muscle protein synthesis (MPS) increased 24% while muscle protein breakdown (MPB) decreased 21%, respectively. These changes in protein turnover resulted in an improved net muscle protein balance in the basal state following RET. Further, the change in basal MPS is positively associated (r = 0.555, p = 0.003) with the change in muscle thickness. CONCLUSION: Post-absorptive muscle protein turnover is associated with muscle hypertrophy during resistance exercise training.

Effects of estrogen on cerebrovascular function: age-dependent shifts from beneficial to detrimental in small cerebral arteries of the rat.

In the present study, interactions of age and estrogen in the modulation of cerebrovascular function were examined in small arteries <150 µM. The hypothesis tested was that age enhances deleterious effects of exogenous estrogen by augmenting constrictor prostanoid (CP)-potentiated reactivity of the female (F) cerebrovasculature. F Sprague-Dawley rats approximating key stages of "hormonal aging" in humans were studied: perimenopausal (mature multi-gravid, MA, cyclic, 5-6 mo of age) and postmenopausal (reproductively senescent, RS, acyclic 10-12 mo of age). Rats underwent bilateral ovariectomy and were given estrogen replacement therapy (E) or placebo (O) for 14-21 days. Vasopressin reactivity (VP, 10(-12)-10(-7) M) was measured in pressurized middle cerebral artery segments, alone or in the presence of COX-1- (SC560, 1 µM) or COX-2- (NS398, 10 µM) selective inhibitors. VP-stimulated release of prostacyclin (PGI2) and thromboxane (TXA2) were assessed by radioimmunoassay of 6-keto-PGF1α and TXB2 (stable metabolites). VP-induced vasoconstriction was attenuated in ovariectomized + estrogen-replaced, multigravid adult rats (5-6 mo; MAE) but potentiated in older ovariectomized + estrogen-replaced, reproductively senescent rats (12-14 mo; RSE). SC560 and NS398 reduced reactivity similarly in ovariectomized multigravid adult rats (5-6 mo; MAO) and ovariectomized reproductively senescent rat (12-14 mo; RSO). In MAE, reactivity to VP was reduced to a greater extent by SC560 than by NS398; however, in RSE, this effect was reversed. VP-stimulated PGI2 was increased by estrogen, yet reduced by age. VP-stimulated TXA2 was increased by estrogen and age in RSE but did not differ in MAO and RSO. Taken together, these data reveal that the vascular effects of estrogen are distinctly age-dependent in F rats. In younger MA, beneficial and protective effects of estrogen are evident (decreased vasoconstriction, increased dilator prostanoid function). Conversely, in older RS, detrimental effects of estrogen begin to be manifested (enhanced vasoconstriction and CP function). These findings may lead to age-specific estrogen replacement therapies that maximize beneficial and minimize detrimental effects of this hormone on small cerebral arteries that regulate blood flow.

Soy-Dairy Protein Blend or Whey Protein Isolate Ingestion Induces Similar Postexercise Muscle Mechanistic Target of Rapamycin Complex 1 Signaling and Protein Synthesis Responses in Older Men.

BACKGROUND: Previous work demonstrated that a soy-dairy protein blend (PB) prolongs hyperaminoacidemia and muscle protein synthesis in young adults after resistance exercise. OBJECTIVE: We investigated the effect of PB in older adults. We hypothesized that PB would prolong hyperaminoacidemia, enhancing mechanistic target of rapamycin complex 1 (mTORC1) signaling and muscle protein anabolism compared with a whey protein isolate (WPI). METHODS: This double-blind, randomized controlled trial studied men 55-75 y of age. Subjects consumed 30 g protein from WPI or PB (25% soy, 25% whey, and 50% casein) 1 h after leg extension exercise (8 sets of 10 repetitions at 70% one-repetition maximum). Blood and muscle amino acid concentrations and basal and postexercise muscle protein turnover were measured by using stable isotopic methods. Muscle mTORC1 signaling was assessed by immunoblotting. RESULTS: Both groups increased amino acid concentrations (P < 0.05) and mTORC1 signaling after protein ingestion (P < 0.05). Postexercise fractional synthesis rate (FSR; P ≥ 0.05), fractional breakdown rate (FBR; P ≥ 0.05), and net balance (P = 0.08) did not differ between groups. WPI increased FSR by 67% (mean ± SEM: rest: 0.05% ± 0.01%; postexercise: 0.09% ± 0.01%; P < 0.05), decreased FBR by 46% (rest: 0.17% ± 0.01%; postexercise: 0.09% ± 0.03%; P < 0.05), and made net balance less negative (P < 0.05). PB ingestion did not increase FSR (rest: 0.07% ± 0.03%; postexercise: 0.09% ± 0.01%; P ≥ 0.05), tended to decrease FBR by 42% (rest: 0.25% ± 0.08%; postexercise: 0.15% ± 0.08%; P = 0.08), and made net balance less negative (P < 0.05). Within-group percentage of change differences were not different between groups for FSR, FBR, or net balance (P ≥ 0.05). CONCLUSIONS: WPI and PB ingestion after exercise in older men induced similar responses in hyperaminoacidemia, mTORC1 signaling, muscle protein synthesis, and breakdown. These data add new evidence for the use of whey or soy-dairy PBs as targeted nutritional interventions to counteract sarcopenia. This trial was registered at clinicaltrials.gov as NCT01847261.

Protein Supplementation Has Minimal Effects on Muscle Adaptations during Resistance Exercise Training in Young Men: A Double-Blind Randomized Clinical Trial.

BACKGROUND: To our knowledge the efficacy of soy-dairy protein blend (PB) supplementation with resistance exercise training (RET) has not been evaluated in a longitudinal study. OBJECTIVE: Our aim was to determine the effect of PB supplementation during RET on muscle adaptation. METHODS: In this double-blind randomized clinical trial, healthy young men [18-30 y; BMI (in kg/m(2)): 25 ± 0.5] participated in supervised whole-body RET at 60-80% 1-repetition maximum (1-RM) for 3 d/wk for 12 wk with random assignment to daily receive 22 g PB (n = 23), whey protein (WP) isolate (n = 22), or an isocaloric maltodextrin (carbohydrate) placebo [(MDP) n = 23]. Serum testosterone, muscle strength, thigh muscle thickness (MT), myofiber cross-sectional area (mCSA), and lean body mass (LBM) were assessed before and after 6 and 12 wk of RET. RESULTS: All treatments increased LBM (P < 0.001). ANCOVA did not identify an overall treatment effect at 12 wk (P = 0.11). There tended to be a greater change in LBM from baseline to 12 wk in the PB group than in the MDP group (0.92 kg; 95% CI: -0.12, 1.95 kg; P = 0.09); however, changes in the WP and MDP groups did not differ. Pooling data from combined PB and WP treatments showed a trend for greater change in LBM from baseline to 12 wk compared with MDP treatment (0.69 kg; 95% CI: -0.08, 1.46 kg; P = 0.08). Muscle strength, mCSA, and MT increased (P < 0.05) similarly for all treatments and were not different (P > 0.10) between treatments. Testosterone was not altered. CONCLUSIONS: PB supplementation during 3 mo of RET tended to slightly enhance gains in whole-body and arm LBM, but not leg muscle mass, compared with RET without protein supplementation. Although protein supplementation minimally enhanced gains in LBM of healthy young men, there was no enhancement of gains in strength. This trial was registered at clinicaltrials.gov as NCT01749189.

Inpatient Walking Activity to Predict Readmission in Older Adults.

OBJECTIVE: To compare the 30-day readmission predictive power of in-hospital walking activity and in-hospital activities of daily living (ADLs) in older acutely ill patients. In addition, we sought to identify preliminary walking thresholds that could support the targeting of interventions aimed at minimizing rehospitalizations. DESIGN: Prospective, observational clinical cohort study. Step counts during hospitalization were assessed via accelerometry. ADL function was assessed within 48 hours of admission. SETTING: Acute care hospital. PARTICIPANTS: One hundred sixty-four ambulatory persons aged 65 years and older admitted to the hospital from the community with an acute medical illness. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Readmission back to the index hospital (yes vs no) within 30 days of discharge. RESULTS: Twenty-six patients (15.8%) were readmitted within 30 days of discharge. Walking activity during hospitalization was more strongly and significantly associated with 30-day readmission (odds ratio=0.90; 95% confidence interval, 0.82-0.98) than ADL function (odds ratio=0.45; 95% confidence interval, 0.14-1.45) after adjusting for relevant readmission risk factors. The predictive accuracy (area under the curve) was highest for models that included walking activity and changed little with the addition of ADLs. A walking threshold of 275 steps or more per day identified patients at reduced 30-day readmission risk. CONCLUSIONS: Walking activity was a stronger predictor of readmission than ADLs. Monitoring patient activity during hospitalization may provide clinicians with valuable information on early readmission risk not captured by measures of ADLs. Further study is needed to replicate these findings and monitor walking activity posthospitalization to further advance our understanding of readmission risk.

Protein intake and muscle function in older adults.

PURPOSE OF REVIEW: We provide an update on the recent advances in nutrition research regarding the role of protein intake in the development and treatment of sarcopenia of aging. RECENT FINDINGS: Specific muscle mass, strength and function cut-points for the diagnosis of sarcopenia have been identified. There is mounting evidence, as highlighted by multiple consensus statements, that the Recommended Dietary Allowance (0.8 g/kg body weight) may be inadequate to promote optimal health in older adults. Recent research indicates that in addition to total daily protein intake the timing of protein intake is also important to best stimulate muscle protein synthesis, and maintain muscle mass and function in older adults. SUMMARY: Recent evidence suggests that the Recommended Dietary Allowance for protein is inadequate, and that the timing and distribution of protein consumption throughout daily meals may be as important as the total quantity. Research has continued to advance our understanding of protein's effects on muscle metabolism; however, there remains a need for large, long-term, randomized clinical trials examining whether the positive effects of dietary protein on muscle metabolism seen in acute studies will translate over the long term into gains of muscle mass, function, and the overall health of older adults.

Enhancing Flow Mediated Dilation Analysis by Optimizing an Open-Source Software with Automated Edge Detection.

Flow mediated dilation (FMD) is a common measure of endothelial function and an indicator of vascular health. Automated software methods exist to improve the speed and accuracy of FMD analysis. Compared to commercial software, open-source software offers similar capabilities at a much lower cost while allowing for increased customization specific to users' needs. We introduced modifications to an existing open-source software, FloWave.us to better meet FMD analysis needs. The purpose of this study was to compare the repeatability and reliability of the modified FloWave.us software to the original software and to manual measurements. To assess these outcomes, Duplex ultrasound imaging data from the popliteal artery in older adults were analyzed. The average percent FMD for the modified software was 6.98±3.68% and 7.27±3.81% for Observer 1 and 2 respectively, compared to 9.17±4.91% and 10.70±4.47% with manual measurements and 5.07±31.79% with the original software for Observer 1. The modified software and manual methods demonstrated higher intra-observer intraclass correlation coefficients (ICCs) for repeated measures for baseline diameter, peak diameter, and percent FMD compared to the original software. For percent FMD, the inter-observer ICC was 0.593 for manual measurements and 0.723 for the modified software. With the modified method an average of 97.7±2.4% of FMD videos frames were read, compared to only 17.9±15.0% frames read with the original method when analyzed by the same observer. Overall, this work further establishes open-source software as a robust and viable tool for FMD analysis and demonstrates improved reliability compared to the original software.

Low growth hormone secretion associated with post-acute sequelae SARS-CoV-2 infection (PASC) neurologic symptoms: A case-control pilot study.

OBJECTIVE: To determine if patients that develop lingering neurologic symptoms of fatigue and "brain fog" after initial recovery from coronavirus disease 2019 (COVID-19) have persistent low growth hormone (GH) secretion as seen in other conditions with similar symptom etiology. DESIGN: In this case-control observational pilot study, patients reporting lingering neurologic post-acute sequelae of SARS-CoV-2 (PASC, n = 10) symptoms at least 6 months after initial infection were compared to patients that recovered from COVID-19 without lingering symptoms (non-PASC, n = 13). We compared basic blood chemistry and select metabolites, lipids, hormones, inflammatory markers, and vitamins between groups. PASC and non-PASC subjects were tested for neurocognition and GH secretion, and given questionnaires to assess symptom severity. PASC subjects were also tested for glucose tolerance and adrenal function. RESULTS: PASC subjects reported significantly worse fatigue, sleep quality, depression, quality of life, and gastrointestinal discomfort compared to non-PASC. Although PASC subjects self-reported poor mental resilience, cognitive testing did not reveal significant differences between groups. Neurologic PASC symptoms were not linked to inflammatory markers or adrenal insufficiency, but were associated with reduced growth hormone secretion. CONCLUSIONS: Neurologic PASC symptoms are associated with gastrointestinal discomfort and persistent disruption of GH secretion following recovery from acute COVID-19. (www. CLINICALTRIALS: gov; NCT04860869).

Exercise training enhances multiple mechanisms of relaxation in coronary arteries from ischemic hearts.

Exercise training of coronary artery disease patients is of considerable interest, since it has been shown to improve vascular function and, thereby, enhance blood flow into compromised myocardial regions. However, the mechanisms underlying exercise-induced improvements in vascular function have not been fully elucidated. We tested the hypothesis that exercise training increases the contribution of multiple mediators to endothelium-dependent relaxation of coronary arteries in the underlying setting of chronic coronary artery occlusion. To induce gradual occlusion, an ameroid constrictor was placed around the proximal left circumflex coronary artery in Yucatan miniature swine. At 8 wk postoperatively, pigs were randomly assigned to sedentary or exercise (treadmill, 5 days/wk) regimens for 14 wk. Exercise training significantly enhanced the contribution of nitric oxide, prostanoids, and large-conductance Ca(2+)-dependent K(+) (BKCa) channels to endothelium-dependent, bradykinin-mediated relaxation in nonoccluded and collateral-dependent arteries. Combined nitric oxide synthase, prostanoid, and BKCa channel inhibition ablated the enhanced relaxation associated with exercise training. Exercise training significantly increased nitric oxide levels in response to bradykinin in endothelial cells isolated from nonoccluded and collateral-dependent arteries. Bradykinin treatment significantly increased PGI2 levels in all artery treatment groups and tended to be further enhanced after nitric oxide synthase inhibition in exercise-trained pigs. No differences were found in whole cell BKCa channel currents, BKCa channel protein levels, or arterial cyclic nucleotide levels. Although redundant, upregulation of parallel vasodilator pathways appears to contribute to enhanced endothelium-dependent relaxation, potentially providing a more refined control of blood flow after exercise training.

The Pre-Adaptation of a Stroke-Specific Self-Management Program Among Older Adults.

Objectives: Managing multimorbidity as aging stroke patients is complex; standard self-management programs necessitate adaptations. We used visual analytics to examine complex relationships among aging stroke survivors' comorbidities. These findings informed pre-adaptation of a component of the Chronic Disease Self-Management Program. Methods: Secondary analysis of 2013-2014 Medicare claims with stroke as an index condition, hospital readmission within 90 days (n = 42,938), and 72 comorbidities. Visual analytics identified patient subgroups and co-occurring comorbidities. Guided by the framework for reporting adaptations and modifications to evidence-based interventions, an interdisciplinary team developed vignettes that highlighted multimorbidity to customize the self-management program. Results: There were five significant subgroups (z = 6.19, p < .001) of comorbidities such as obesity and cancer. We constructed 6 vignettes based on the 5 subgroups. Discussion: Aging stroke patients often face substantial disease-management hurdles. We used visual analytics to inform pre-adaptation of a self-management program to fit the needs of older adult stroke survivors.

Racial and ethnic differences in the improvement in daily activities during a nursing home stay.

BACKGROUND: Improving independence in daily activities is an important outcome of postacute nursing home care. We investigated racial and ethnic differences in the improvement in activities of daily living (ADL) during a skilled nursing facility (SNF) stay among Medicare fee-for-service beneficiaries with a hip fracture, joint replacement, or stroke. METHODS: This was a retrospective study of Medicare beneficiaries admitted to a SNF between 01/01/2013 and 9/30/2015. The final sample included 428,788 beneficiaries admitted to a SNF within 3 days of hospital discharge for a hip fracture (n = 118,790), joint replacement (n = 245,845), or stroke (n = 64,153). Data from residents' first and last Minimum Data Set were used to calculate ADL total scores for self-performance in dressing, personal hygiene, toileting, locomotion on the unit, transferring, bed mobility, and eating. Residents were dichotomized according to having had any improvement in the ADL total score. Multivariable logistic regression models that included a random intercept for the facility were used to estimate the adjusted odds ratios for any improvement in ADL function among black and Hispanic residents compared to white residents. RESULTS: A total of 299,931 residents (69.9%) had any improvement in ADL function. Black residents (OR:0.94; 95% CI: 0.91-0.98) but not Hispanic residents (OR: 0.98; 95% CI: 0.94-1.03) had significantly lower odds to have any improvement in ADL function. Analyses stratified by the reason for prior hospitalization indicated that black residents discharged for hip fracture (OR: 0.87; 95% CI: 0.80-0.93) and stroke (OR: 0.87; 95% CI: 0.83-0.93), but not joint replacement (OR: 1.02; 95% CI: 0.97-1.06) had significantly lower odds for any ADL improvement compared to white residents. CONCLUSIONS: Our findings are evidence for racial disparities in the improvement in ADL function during a SNF stay. Future research should investigate systemic factors that may contribute to disparities in the improvement in ADL function during a SNF stay.

The Influence of Prior Functional Status on Self-Care Improvement During a Skilled Nursing Facility Stay.

OBJECTIVES: Older adults' prior health status can influence their recovery after a major illness. We investigated the association between older adults' independence in self-care tasks prior to a skilled nursing facility (SNF) stay and their self-care function at SNF admission, discharge, and the change in self-care function during an SNF stay. DESIGN: Retrospective study of 100% national CMS data files from October 1, 2018, to December 31, 2019. SETTINGS AND PARTICIPANTS: The sample included 616,073 Medicare fee-for-service beneficiaries who were discharged from an SNF between October 1, 2018, and December 31, 2019. METHODS: The admission Minimum Data Set (MDS) was used to determine residents' prior ability (independent, some help, dependent) to complete self-care tasks before the current illness, exacerbation, or injury. Seven self-care tasks from MDS Section GG were used to calculate total scores (range 7-42 points) for self-care at admission, discharge, and the change in self-care between admission and discharge. RESULTS: Most residents (62.0%) were independent, 35.3% needed some help, and 2.64% were dependent in self-care prior to SNF admission. Nearly 25% of residents with urinary incontinence, 28.8% with bowel incontinence, and 31.7% with moderate-severe cognitive impairment were independent in self-care prior to SNF admission compared with approximately 70% of residents without these conditions. Compared with residents who were dependent in self-care prior to SNF admission, those who were independent or needed some help had significantly higher self-care total scores at admission (5.67 vs 4.21 points, respectively) and discharge (6.44 vs 3.82 points, respectively) and exhibited greater improvement in self-care (3.48 vs 1.62 points, respectively). CONCLUSIONS AND IMPLICATIONS: Our findings are evidence that the new MDS item for a resident's independence in self-care tasks before SNF admission is a valid measure of their prior self-care function. This is clinically useful information and should be considered when developing rehabilitation goals.

Dietary Intake Patterns of Community-Dwelling Older Adults After Acute Hospitalization.

BACKGROUND: Malnutrition and sarcopenia are a growing concern in community-dwelling older adults. Hospitalization increases the risk of malnutrition and leads to a decline in functional and nutritional status at discharge. Persistent malnutrition after hospital discharge may worsen posthospital outcomes, including readmissions. The aim of this study was to determine dietary intakes and nutrient distribution patterns of community-dwelling older adults after acute hospitalization. METHOD: Participants (65 years and older, n = 85) were enrolled during acute hospitalization and dietary 24-hour recalls were collected weekly for 1 month postdischarge. Analysis included change in dietary intake over recovery timeframe; daily intake of energy, protein, fruit, vegetables, and fluids; comparison of intake to recommendations; distribution of energy and protein across mealtimes; and analysis of most common food choices. RESULTS: Most participants did not meet current recommendations for energy, fruit, vegetables, or fluids. Average protein consumption was significantly higher than the current recommendation of 0.8 g/kg/d; however, only 55% of participants met this goal and less than 18% met the 1.2 g/kg/d proposed optimal protein intake for older adults. The protein distribution throughout the day was skewed and no one met the 0.4 g/meal protein recommendation at all meals. CONCLUSIONS: Our findings indicate that community-dwelling older adults did not meet their nutritional needs during recovery after hospitalization. These data highlight the need for better nutritional evaluation and support of geriatric patients recovering from hospitalization.

Association between Sleep Quality and Mental Health among Patients at a Post-COVID-19 Recovery Clinic.

A growing body of research documents the persistence of physical and neuropsychiatric symptoms following the resolution of acute COVID-19 infection. To the best of our knowledge, no published study has examined the interaction between insomnia and mental health. Accordingly, we proposed to examine new diagnoses of insomnia, and referrals to pulmonary and sleep medicine clinics for treatment of sleep disorders, in patients presenting to one post-acute COVID-19 recovery clinic. Additionally, we aimed to examine the relationship between poor sleep quality, depression, anxiety, and post-traumatic stress. Patients presented to the clinic on average 2 months following COVID-19 infection; 51.9% (n = 41) were hospitalized, 11.4% (n = 9) were in the intensive care unit, 2.5% (n = 2) were on a mechanical ventilator, and 38.0% (n = 30) were discharged on oxygen. The most commonly reported symptom was fatigue (88%, n = 70), with worse sleep following a COVID-19 infection reported in 50.6% (n = 40). The mean PSQI score was 9.7 (82.3%, n = 65 with poor sleep quality). The mean GAD-7 score was 8.3 (22.8%, n = 14 with severe depression). The mean PHQ-9 was 10.1 (17.8%, n = 18 with severe anxiety). The mean IES-6 was 2.1 (54.4%, n = 43 with post-traumatic stress). Poor sleep quality was significantly associated with increased severity of depression, anxiety, and post-traumatic stress. Future work should follow patients longitudinally to examine if sleep, fatigue, and mental health symptoms improve over time.

Impact of COVID-19 Infection and Persistent Lingering Symptoms on Patient Reported Indicators of Nutritional Risk and Malnutrition.

Persistent malnutrition after COVID-19 infection may worsen outcomes, including delayed recovery and increased risk of rehospitalization. This study aimed to determine dietary intakes and nutrient distribution patterns after acute COVID-19 illness. Findings were also compared to national standards for intake of energy, protein, fruit, and vegetables, as well as protein intake distribution recommendations. Participants (≥18 years old, n = 92) were enrolled after baseline visit at the Post-COVID Recovery Clinic. The broad screening battery included nutritional assessment and 24-h dietary recall. Participants were, on average, 53 years old, 63% female, 69% non-Hispanic White, and 59% obese/morbidly obese. Participants at risk for malnutrition (48%) experienced significantly greater symptoms, such as gastric intestinal issues, loss of smell, loss of taste, or shortness of breath; in addition, they consumed significantly fewer calories. Most participants did not meet recommendations for fruit or vegetables. Less than 39% met the 1.2 g/kg/day proposed optimal protein intake for recovery from illness. Protein distribution throughout the day was skewed; only 3% met the recommendation at all meals, while over 30% never met the threshold at any meal. Our findings highlight the need for nutritional education and support for patients to account for lingering symptoms and optimize recovery after COVID-19 infection.

Improvements in sleep quality and fatigue are associated with improvements in functional recovery following hospitalization in older adults.

Study objectives: Poor sleep quality, a frequent problem in older adults, has been shown to be associated with reduced physical function and wellbeing. However, little is known about the relationship between sleep quality and the recovery of physical function following hospitalization. Thus, we conducted this study to examine the association between sleep quality and functional recovery after an acute hospitalization in community dwelling older adults. Methods: Older adult patients (N = 23, mean age = 74 ± 9 years) were recruited during an acute hospitalization (average length of stay 3.9 days) with a cardiovascular (56%), pulmonary (22%), or metabolic (13%) admission diagnosis. Objective physical function was measured using the Short Physical Performance Battery (SPPB) and self-reported function was assessed with Katz Index of Independence in Activities of Daily Living (ADL) and Lawton Instrumental Activities of Daily Living Scale (IADL). Sleep quality was measured using Pittsburgh Sleep Quality Index (PSQI) global score and Iowa Fatigue Score (IFS). Testing was performed prior to discharge (baseline) and 4-weeks post-discharge (follow-up). Results: Regression models showed PSQI Subjective Sleep Quality change scores from baseline to 4-week follow-up predicted a change in ADL (ß = -0.22); PSQI Use of Sleep Medications change scores predicted a change in SPPB Total (ß = 1.62) and SPPB Chair Stand (ß = 0.63); IFS change scores predicted SPPB Total (ß = -0.16) and SPPB Chair Stand performance (ß = -0.07) change scores. Conclusions: For older adults, changes in sleep medication use, daytime dysfunction, and fatigue were associated with improvements in functional recovery (including physical performance and independence) from acute hospitalization to 4-week follow-up. These results suggest that interventions focused on improving sleep quality, daytime consequences, and fatigue might help enhance physical functioning following hospitalization. Clinical trial registration: ClinicalTrials.gov, identifier: NCT02203656.

Feasibility and Acceptability of an Active Video Game-Based Physical Activity Support Group (Pink Warrior) for Survivors of Breast Cancer: Randomized Controlled Pilot Trial.

BACKGROUND: Survivors of breast cancer with functional limitations have a 40% higher mortality rate than those without. Despite the known benefits of physical activity (PA), <40% of survivors of breast cancer meet the recommendations for PA. The combination of active video games (AVGs) and group-based PA counseling may hold potential for motivating PA adoption and improving physical function. However, this method has not been widely studied in survivors of breast cancer. OBJECTIVE: We aimed to determine the feasibility and acceptability of a group AVG-based multicomponent PA intervention and estimate its effect size and variability on PA and physical function in female survivors of breast cancer in a clinic setting. METHODS: Female survivors of breast cancer (N=60) were recruited through the clinic and randomly assigned to the intervention group (12 weekly sessions) or the control group (existing support group). The intervention group received game-based pedometers and participated in weekly group AVG sessions, PA behavioral coaching, and survivorship navigation discussions. A participant manual with weekly reflection worksheets was provided to reinforce the coaching lessons and promote self-led PA. The control group received conventional pedometers and participated in an existing breast cancer support group. Feasibility was assessed by enrollment rate (≥50%), retention rate (≥80%), group attendance rate (75% attending ≥9 sessions [intervention group]), and the number of technological issues and adverse events. Acceptability was measured by participants' attitudes (from strongly disagree=1 to strongly agree=5) toward the use of AVGs and the overall program. The outcomes included PA (accelerometers) and physical function (Short Physical Performance Battery and gait speed). Analysis of covariance was used to determine differences in PA and physical function between the groups. The Cohen d and its 95% CI determined the effect size and variability, respectively. All the analyses followed the intention-to-treat principle. RESULTS: Participants were an average of 57.4 (SD 10.5) years old, 70% (42/60) White, and 58% (35/60) off treatment. The enrollment rate was 55.9% (66/118). Despite substantial long-term hurricane-related disruptions, we achieved an 80% (48/60) retention. The intervention group's attendance rate was 78% (14/18), whereas the control group's attendance rate was 53% (9/17). Of the 26 game-based pedometers, 3 (12%) were damaged or lost. No study-related adverse events occurred. Acceptability items were highly rated. Steps (ß=1621.64; P=.01; d=0.72), Short Physical Performance Battery (ß=.47; P=.01; d=0.25), and gait speed (ß=.12; P=.004; d=0.48) had a significant intervention effect. CONCLUSIONS: The intervention was feasible and acceptable in this population despite the occurrence of a natural disaster. Pilot results indicate that group AVG sessions, PA coaching, and survivorship navigation produced moderate effects on PA and physical functioning. AVGs with PA counseling can potentially be used in existing breast cancer support groups to encourage PA and improve physical function. TRIAL REGISTRATION: ClinicalTrials.gov NCT02750241; https://clinicaltrials.gov/ct2/show/NCT02750241.