Older adults' perceptions of early rehabilitation and recovery after hip fracture surgery: a UK qualitative study.

PURPOSE: To explore older adult's perceptions of early rehabilitation and recovery after hip fracture, as a complement to the UK standards for acute physiotherapy after hip fracture. METHODS: In-depth semi-structured interviews with 15 adults aged 60 years or more in hospital after hip fracture surgery. A thematic analysis approach with interpretation informed by Bury's biographical disruption theoretical framework. RESULTS: Participants voiced the importance of self-determination, professional support, meaningful feedback, and social capital after hip fracture. Collaborative working with staff was required for meeting the UK standards. Participants voiced anxieties about their hip fracture when considered in conjunction with their age and co-existing conditions, anticipating a disruption to their previous physical and social activities. This new, more dependent, life situation was not acceptable to participants. CONCLUSIONS: This study suggests hip fracture alone, was not perceived as a biographical disruption by older adults although it is presented as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions. For successful implementation of the UK standards, goal setting should consider patients in the wider context of their advancing age and co-existing conditions to empower them to define a fresh narrative of self.Implications for rehabilitationHip fracture was perceived as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions.Participants expressed uncertainty over their ability to recover their previous identity in the absence of professional support and/or social capital.Healthcare professionals need to educate and empower older adults to take charge of their own recovery.For successful implementation of the UK standards for acute physiotherapy, there is a need to contextualize goal setting to empower patients to define a fresh narrative of self.

Discharge after hip fracture surgery in relation to mobilisation timing by patient characteristics: linked secondary analysis of the UK National Hip Fracture Database.

BACKGROUND: Early mobilisation leads to a two-fold increase in the adjusted odds of discharge by 30-days compared to late mobilisation. Whether this association varies by patient characteristics identified as reasons for delayed mobilisation is unknown. METHODS: Audit data was linked to hospitalisation records for 133,319 patients 60 years or older surgically treated for hip fracture in England or Wales between 2014 and 2016. Adjusted proportional odds regression models tested whether the cumulative incidences of discharge differed between those mobilised early and those mobilised late for subgroups defined by dementia, delirium, hypotension, prefracture ambulation, and prefracture residence, accounting for the competing risk of death. RESULTS: Overall, 34,253 patients presented with dementia, 9818 with delirium, and 10,123 with hypotension. Prefracture, 100,983 were ambulant outdoors, 30,834 were ambulant indoors only, 107,144 were admitted from home, and 23,588 from residential care. 1502 had incomplete data for ambulation and 2587 for prefracture residence. 10, 8, 8, 12, and 12% fewer patients with dementia, delirium, hypotension, ambulant indoors only prefracture, or admitted from residential care mobilised early when compared to those who presented without dementia, delirium, hypotension, with outdoor ambulation prefracture, or admitted from home. The adjusted odds ratios of discharge by 30-days postoperatively among those who mobilised early compared with those who mobilised late were 1.71 (95% CI 1.62-1.81) for those with dementia, 2.06 (95% CI 1.98-2.15) without dementia, 1.56 (95% CI 1.41-1.73) with delirium, 2.00 (95% CI 1.93-2.07) without delirium, 1.83 (95% CI, 1.66-2.02) with hypotension, 1.95 (95% CI, 1.89-2.02) without hypotension, 2.00 (95% CI 1.92-2.08) with outdoor ambulation prefracture, 1.80 (95% CI 1.70-1.91) with indoor ambulation only prefracture, 2.30 (95% CI 2.19-2.41) admitted from home, and 1.64 (95% CI 1.51-1.77) admitted from residential care, accounting for the competing risk of death. CONCLUSION: Irrespective of dementia, delirium, hypotension, prefracture ambulation or residence, early compared to late mobilisation increased the likelihood of hospital discharge by 30-days postoperatively. However, fewer patients with dementia, delirium, or hypotension, poorer prefracture ambulation, or from residential care mobilised early. There is a need reduce this care gap by ensuring sufficient resource to enable all patients to benefit from early mobilisation.

The 30-day survival and recovery after hip fracture by timing of mobilization and dementia : a UK database study.

AIMS: The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery. METHODS: Analysis of the National Hip Fracture Database and hospital records for 126,897 patients aged ≥ 60 years who underwent surgery for a hip fracture in England and Wales between 2014 and 2016. Using logistic regression, we adjusted for covariates with a propensity score to estimate the association between the timing of mobilization, survival, and recovery of walking ability. RESULTS: A total of 99,667 patients (79%) mobilized early. Among those mobilized early compared to those mobilized late, the weighted odds ratio of survival was 1.92 (95% confidence interval (CI) 1.80 to 2.05), of recovering outdoor ambulation was 1.25 (95% CI 1.03 to 1.51), and of recovering indoor ambulation was 1.53 (95% CI 1.32 to 1.78) by 30 days. The weighted probabilities of survival at 30 days post-admission were 95.9% (95% CI 95.7% to 96.0%) for those who mobilized early and 92.4% (95% CI 92.0% to 92.8%) for those who mobilized late. The weighted probabilities of regaining the ability to walk outdoors were 9.7% (95% CI 9.2% to 10.2%) and indoors 81.2% (95% CI 80.0% to 82.4%), for those who mobilized early, and 7.9% (95% CI 6.6% to 9.2%) and 73.8% (95% CI 71.3% to 76.2%), respectively, for those who mobilized late. Patients with dementia were less likely to mobilize early despite observed associations with survival and ambulation recovery for those with and without dementia. CONCLUSION: Early mobilization is associated with survival and recovery for patients (with and without dementia) after hip fracture. Early mobilization should be incorporated as a measured indicator of quality. Reasons for failure to mobilize early should also be recorded to inform quality improvement initiatives. Cite this article: Bone Joint J 2021;103-B(7):1317-1324.

Discharge after hip fracture surgery by mobilisation timing: secondary analysis of the UK National Hip Fracture Database.

OBJECTIVE: To determine whether mobilisation timing was associated with the cumulative incidence of hospital discharge by 30 days after hip fracture surgery, accounting for potential confounders and the competing risk of in-hospital death. METHOD: We examined data for 135,105 patients 60 years or older who underwent surgery for nonpathological first hip fracture between 1 January 2014 and 31 December 2016 in any hospital in England or Wales. We tested whether the cumulative incidences of discharge differed between those mobilised early (within 36 h of surgery) and those mobilised late, accounting for potential confounders and the competing risk of in-hospital death. RESULTS: A total of 106,722 (79%) of patients first mobilised early. The average rate of discharge was 39.2 (95% CI 38.9-39.5) per 1,000 patient days, varying from 43.1 (95% CI 42.8-43.5) among those who mobilised early to 27.0 (95% CI 26.6-27.5) among those who mobilised late, accounting for the competing risk of death. By 30-day postoperatively, the crude and adjusted odds ratios of discharge were 2.36 (95% CI 2.29-2.43) and 2.08 (95% CI 2.00-2.16), respectively, among those who first mobilised early compared with those who mobilised late, accounting for the competing risk of death. CONCLUSION: Early mobilisation led to a 2-fold increase in the adjusted odds of discharge by 30-day postoperatively. We recommend inclusion of mobilisation within 36 h of surgery as a new UK Best Practice Tariff to help reduce delays to mobilisation currently experienced by one-fifth of patients surgically treated for hip fracture.

Preparation and evaluation of zeolites for ammonium removal from municipal wastewater through ion exchange process.

The application of ion exchange process for ammonium (NH4+-N) removal from wastewater is limited due to the lack of suppliers of engineered zeolites which present high ammonium exchange capacity (AEC) and mechanical strength. This study focuses on the preparation and evaluation of synthetic zeolites (Zeolite1-6) by measuring AEC and resistance to attrition and compression, against natural (clinoptilolite) and engineered zeolite (reference, Zeolite-N). At high NH4+-N concentrations, Zeolite6 and Zeolite2 showed capacities of 4.7 and 4.5 meq NH4+-N/g media, respectively. In secondary effluent wastewater (initial NH4+-N of 0.7 meq NH4+-N/L), Zeolite1, 2 and 6 showed an AEC of 0.05 meq NH4+-N/g media, similar to Zeolite-N (0.06 meq NH4+-N /g media). Among the synthetic zeolites, Zeolite3 and 6 showed higher resistance to attrition (disintegration rate = 2.7, 4.1 NTU/h, respectively) when compared with Zeolite-N (disintegration rate = 13.2 NTU/h). Zeolite4 and 6 showed higher resistance to compression (11 N and 6 N, respectively). Due its properties, Zeolite6 was further tested in an ion exchange demonstration scale plant treating secondary effluent from a municipal wastewater treatment plant. However, Zeolite6 disintegrated after 2 months of operation, whilst Zeolite-N remained stable for 1.5 year. This highlighted the importance of the zeolite's mechanical strength for successful application. In particular, future work should focus on the optimization of the zeolite production process (temperature, time and dimension of the kiln during calcination) to obtain an engineered zeolite with a spherical shape thus reducing eventual sharp edges which can affect mechanical strength.

A definition for influenza pandemics based on historical records.

OBJECTIVE: To analyse the records of past influenza outbreaks to determine a definition for pandemics. METHODS: Analysis of publications of large outbreaks of influenza which have occurred since 1889/90, and to match the results against the current definitions of an influenza pandemic. RESULTS: According to the general understanding of a pandemic, nine outbreaks of influenza since 1889/90 satisfy the definition; however, for two of these, occurring in 1900 and 1933, the data are limited. The special condition for an influenza pandemic requires, in one definition, that the virus strain responsible could not have arisen from the previous circulating strain by mutation; and in the second, that the new strain be a different subtype to the previously circulating strain. Both these restrictions deny pandemic status to two, and possibly three, influenza outbreaks which were pandemics according to the more general understanding of the term. These observations suggest that a re-evaluation of the criteria which define influenza pandemics should be carried out. CONCLUSION: The contradiction outlined above brings the previous definitions of an influenza pandemic into question; however, this can be resolved by defining an influenza pandemic by the following criteria. Thus, an influenza pandemic arises at a single, specific place and spreads rapidly to involve numerous countries. The haemagglutinin (HA) of the emergent virus does not cross-react serologically with the previously dominant virus strain(s), and there is a significant lack of immunity in the population against the emergent virus. These three criteria are interlinked and can be determined early to alert authorities who could respond appropriately. Other criteria associated with pandemics are necessarily retrospective, although important and valid. The implications of this definition are discussed.

End-product control of expression of branched-chain amino acid biosynthesis genes in Streptomyces coelicolor A3(2): paradoxical relationships between DNA sequence and regulatory phenotype.

The branched-chain protein amino acids isoleucine, valine and leucine can provide precursors for synthesis of complex polyketide secondary metabolites in streptomycetes; therefore the regulation of their own synthesis is of interest. DNA sequences upstream of ilvBNC, ilvD, leuA, leuB, ilvE and leuCD in Streptomyces coelicolor A3(2) have been obtained in this laboratory or as part of the S. coelicolor genome sequencing project. Upstream of ilvB and leuA, typical features of classical attenuator systems can be discerned, in particular hypothetical short ORFs with runs of Ile/Val/Leu and Leu codons, respectively. No such features are apparent upstream of other genes or gene clusters present. All five upstream regions were fused to xylE (encoding catechol dioxygenase, CO) as a reporter gene in the SCP2*-based low-copy-number vector pIJ2839. All wild-type regions showed strong depression of CO activity in the presence of all three branched-chain amino acids whether or not the attenuation features were present. By site-directed mutagenesis, the Ile/Val/Leu and Leu triplets in the putative attenuator peptides for ilvB and leuA were replaced by ones for other amino acids. In the case of ilvB, this had no effect at all; for leuA, the wild-type regulatory phenotype persisted in at least some experiments. It was concluded that (i) an unknown regulatory mechanism must be operating in the ilv/leu system of S. coelicolor A3(2) in place of classical attenuation; and (ii) it is unsafe to infer the functioning of a regulatory mechanism from sequence homologies alone.