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.

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.

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.

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.

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.

Dravet syndrome: Effects on informal caregivers' mental health and quality of life - A systematic review.

BACKGROUND: Dravet syndrome (DS) is a severe developmental and epileptic encephalopathy, with predictable negative consequences for informal caregivers' mental health. This systematic review aimed to evaluate the representativeness of depression, anxiety, and burden in these caregivers and assess their quality of life. METHODS: The PRISMA recommendations were followed, and a comprehensive search was conducted on PubMed/MEDLINE, WoS and Scopus databases, without date or language limits. Only observational quantitative studies on adult informal caregivers of patients with DS were considered. RESULTS: Of 876 records found, 21 full-text articles were assessed and only 6 met the inclusion criteria. The latter have mostly a cross-sectional design and include samples composed by 19 to 742 caregivers, mainly mothers/females. Most of the study participants had a Bachelor's degree/higher educational level and were married. An important incidence of depression and anxiety on DS caregivers was reported, with significantly higher levels compared with population norms and with carers of other patients with epilepsy. Depression/anxiety were shown to be significantly associated with caregivers' fatigue and compromised sleep quality. Other important aspects of burden have been identified; however, comparisons between studies were not possible as different scales were used. Caregivers' health-related quality of life is also affected, with mothers reporting a worse perception on this domain. CONCLUSIONS: Mental health and quality of life of DS caregivers are compromised, with mothers bearing an apparently greater burden. Studies using validated instruments for this population to assess the previously considered outcomes are needed, in order to inform the development of preventive strategies and problem-oriented interventions.

Frailty phenotype and associated nutritional factors in a sample of Portuguese outpatients with heart failure.

BACKGROUND AND AIM: Frailty phenotype (FP) is very common in heart failure (HF) and both syndromes worsen one another. The aim of this study is to first describe FP in a sample of Portuguese patients with HF, and to analyse its association with nutritional and clinical statuses, namely, muscle mass, obesity and functional class. METHODS AND RESULTS: In this cross-sectional study, a sample of 136 outpatients with HF (24-81 years, 33.8% women) were randomly selected from the appointments' listings of a HF and Transplant clinic in a Portuguese University Hospital. FP was assessed according to Fried et al. muscle mass was estimated from the mid-upper arm muscle circumference; weight status was assessed using the body mass index; HF functional classes were registered. The association between participants' characteristics and FP categories was analysed using logistic ordinal regression. The frequency of pre-frailty and frailty is 57.4% and 15.4%, respectively. Within frail individuals, 52.4% were under the age of 65. In multivariable analysis, frailty was positively associated with age 70 or older (OR = 3.44) and obesity (OR = 2.66), and negatively associated with muscle mass (OR = 0.77) and HF functional classes I (OR = 0.14) or II (OR = 0.29). CONCLUSION: Muscle mass seems to be an important predictor of frailty in patients with HF and should be taken into account when designing intervention plans that allow for reverting or modifying frailty and pre-frailty. Younger patients should be monitored for the presence and evolution of FP.

Subannular Tubes in Children With Cleft Palate.

OBJECTIVE: To investigate subannular tube (SAT) placement as an alternative treatment of chronic middle ear disease in children with cleft palate. DESIGN: Retrospective cohort study. PARTICIPANTS: All children with cleft palate with intractable otitis media with effusion and/or with tympanic membrane retraction, operated for insertion of 1 or more sets of transtympanic tubes followed by SAT in a tertiary center. MAIN OUTCOME MEASURES: Audiological outcomes, average duration of tubes, and postoperative complications were analyzed. RESULTS: This study included 21 children with cleft palate, aged 3 to 14 years. A total of 38 ears was evaluated. The median time of follow-up was 42 months. During follow-up, 69.2% of the patients had no complications. Observed complications were otorrhea (13.5%) and tube obstruction (7.7%). In 7.9% of the cases, otitis media with effusion relapsed after tube extrusion. By the end of the study, 76.3% of the tubes remained in situ and 68.4% of the tympanic membranes had the SAT in place and had no significant alterations. The mean duration of SATs was 16 months, which was significantly superior to transtympanic tube duration. A significant sustained improvement in the hearing of children with SATs was observed. CONCLUSION: Subannular tube insertion results in hearing improvement to normal range and tympanic retraction pockets reversion in children with cleft palate with persistent otitis media with effusion and tympanic retraction/atelectasis. This surgery appears to be safe and provides long-term efficient middle ear aeration. Strict postoperative follow-up is crucial for the success of the treatment.

Regional differences in residential demand for very high bandwidth broadband internet in 2025.

The future demand for data and the role of gigabit networks are central issues in the context of Next Generation Access (NGA) network roll-out. Based on a generic model, which allows to predict unconstrained future broadband demand in different regions and countries, the authors compare the results for Germany, the UK and the Flemish region, and discuss reasons for the different outcomes. The generic market potential model thereby allows to project the future demand for bandwidth from residential customers on the basis of applications and their bandwidth needs, user profiles and population structure on a household level. Despite a general trend towards an increasing need for broadband, there are clear differences. On the one hand, these point to the relevance of socio-demographic factors for broadband adoption. On the other hand, the relatively high proportion of refusals shows that there is still a need for further educational work on the part of public authorities and providers. Finally, it has to be stated, that our forecast relies on the assumption that connectivity and thus that the availability of area-wide gigabit capable broadband access does not represent a bottleneck.

What effect does delirium have on family and nurses of older adult patients?

OBJECTIVES: This study aims to analyse the level of distress caused by delirium in patients' family and their nurses, and to identify factors associated with psychological distress in families of older adult inpatients in Intermediate Care Units/IMCUs regarding their global experience during hospitalization. METHOD: A prospective pilot study was carried out with families and nurses of older adult patients (≥65 y.o.) consecutively recruited from two IMCUs in Intensive Care Medicine Service in a University Hospital. Patients with Glasgow Coma Scale ≤11, brain injury, blindness/deafness and inability to communicate were excluded. Delirium was daily assessed with Confusion Assessment Method/CAM. The distress level regarding this episode in family and nurses was measured with Delirium Experience Questionnaire/DEQ. Family psychological distress of all recruited patients was assessed with Kessler Psychological Distress Scale/K10. RESULTS: This study included 42 inpatients (mean age/MA = 78 y.o., 50% women), 32 families (68.8% sons/daughters, MA = 50.6 y.o., 81.3% women) and 12 nurses caring for delirium patients (MA = 33 y.o., all women). A total of 12 (28.6%) patients had delirium. Distress related to this episode were higher for families than for nurses (M = 3 vs. M = 2), but differences did not reach statistical significance (Z = -1.535, p = 0.125). The hierarchical regression model explained 44.3% of variability in family psychological distress. Higher levels of psychological distress were associated with living with the patient (p = 0.029), presence of previous cognitive decline (p = 0.048) and development of delirium (p = 0.010). CONCLUSION: These preliminary results show that family psychological distress is higher, when older adult patients developed delirium during hospitalization. Particular attention to these family carers should be given in future development of psychological support and psychoeducational interventions.

Delirium in elderly patients: association with educational attainment.

OBJECTIVE: Among cognitive reserve markers, educational attainment is the most widely studied, with several studies establishing a strong association with risk of dementia. However, it has not yet been fully examined in delirium. This study aims to analyse the relationship between educational attainment and delirium. METHODS: The study included elderly hospitalised patients admitted (≥48 h) into an intermediate care unit (IMCU) of Intensive Care Medicine Service. Exclusion criteria were as follows: Glasgow Coma Scale (total≤11), blindness/deafness, inability to communicate or to speak Portuguese. The European Portuguese Version of the Confusion Assessment Method (CAM) was used for delirium assessment. RESULTS: The final sample (n=157) had a mean age of 78.8 (SD=7.6) the majority being female (52.2%), married (51.5%) and with low educational level (49%). According to CAM, 21% of the patients had delirium. The delirium group presented the fewest years of education (median 1 vs. 4), with statistical significance (p=0.003). Delirium was more frequent among male patients [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.12-0.86; p=0.023], as well as those patients with lower education (OR 0.76; 95% CI 0.62-0.95; p=0.016), and with respiratory disease (OR 3.35; 95% CI 1.20-9.33; p=0.020), after controlling for age and medication. CONCLUSION: Similar to previous studies, these findings point to a negative correlation between education and delirium. This study appears as an attempt to contribute to the knowledge about the role of cognitive reserve in risk of delirium, particularly because is the first one that has been carried out in an IMCU, with lower educated elderly patients. Further studies are needed to clarify this relationship considering other markers (e.g. cognitive activities), which can contribute to the definition of preventive strategies.

Validation study of the European Portuguese version of the Confusion Assessment Method (CAM).

BACKGROUND: The Confusion Assessment Method (CAM) is the most widely used delirium screening instrument. The aim of this study was to evaluate the reliability and validity of the European Portuguese version of CAM. METHODS: The sample included elderly patients (≥65 years), admitted for at least 48 h, into two intermediate care units (ICMU) of Intensive Medicine and Surgical Services in a university hospital. Exclusion criteria were: score ≤11 on the Glasgow Coma Scale (GCS), blindness/deafness, inability to communicate and to speak Portuguese. For concurrent validity, a blinded assessment was conducted by a psychiatrist (DSM-IV-TR, as a reference standard) and by a trained researcher (CAM). This instrument was also compared with other cognitive measures to evaluate convergent validity. Inter-rater reliability was also assessed. RESULTS: In this sample (n = 208), 25% (n = 53) of the patients had delirium, according to DSM-IV-TR. Using this reference standard, the CAM had a moderate sensitivity of 79% and an excellent specificity of 99%. The positive predictive value was 95%, indicating a strong ability to confirm delirium with a positive test result, and the negative predictive value was lower (93%). Good convergent validity was also found, in particular with Mini-Mental State Examination (MMSE) (rs = -0.676; p ≤0.01) and Digit Span Test (DST) forward (rs = -0.605; p ≤0.01), as well as a high inter-rater reliability (diagnostic k = 1.00; single items' k between 0.65 and 1.00). CONCLUSION: Robust results on concurrent and convergent validity and good reliability were achieved. This version was shown to be a valid and reliable instrument for delirium detection in elderly patients hospitalized in intermediate care units.

Comparative study of photoreceptor and retinal ganglion cell topography and spatial resolving power in Dipsadidae snakes.

The diurnal Dipsadidae snakes Philodryas olfersii and P. patagoniensis are closely related in their phylogeny but inhabit different ecological niches. P. olfersii is arboreal, whereas P. patagoniensis is preferentially terrestrial. The goal of the present study was to compare the density and topography of neurons, photoreceptors, and cells in the ganglion cell layer in the retinas of these two species using immunohistochemistry and Nissl staining procedures and estimate the spatial resolving power of their eyes based on the ganglion cell peak density. Four morphologically distinct types of cones were observed by scanning electron microscopy, 3 of which were labeled with anti-opsin antibodies: large single cones and double cones labeled by the antibody JH492 and small single cones labeled by the antibody JH455. The average densities of photoreceptors and neurons in the ganglion cell layer were similar in both species (∼10,000 and 7,000 cells·mm(-2), respectively). The estimated spatial resolving power was also similar, ranging from 2.4 to 2.7 cycles·degree(-1). However, the distribution of neurons had different specializations. In the arboreal P. olfersii, the isodensity maps had a horizontal visual streak, with a peak density in the central region and a lower density in the dorsal retina. This organization might be relevant for locomotion and hunting behavior in the arboreal layer. In the terrestrial P. patagoniensis, a concentric pattern of decreasing cell density emanated from an area centralis located in the naso-ventral retina. Lower densities were observed in the dorsal region. The ventrally high density improves the resolution in the superior visual field and may be an important adaptation for terrestrial snakes to perceive the approach of predators from above.

Pilot study on the European Portuguese version of the Confusion Assessment Method.

OBJECTIVE: To present the pilot study on the European Portuguese validation of the Confusion Assessment Method (CAM). METHODS: The translation process was carried out according to International Society Pharmacoeconomics and Outcomes Research guidelines with trained researchers and inter-rater reliability assessment. The study included 50 elderly patients, admitted (≥24 h) to two intermediate care units. Exclusion criteria were: Glasgow Coma Scale (total score ≤11), blindness/deafness, inability to communicate and not able to speak Portuguese. The sensitivity and specificity of CAM were assessed, with DSM-IV-TR criteria of delirium used as a reference standard. RESULTS: Findings revealed excellent inter-rater reliability (k>0.81), moderate sensitivity (73%) and excellent specificity (95%). CONCLUSION: These preliminary results suggested that this version emerges as a promising diagnostic instrument for delirium.

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.

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.

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.

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.

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.

Production, purification and characterisation of polysaccharides from Pleurotus ostreatus with antitumour activity.

BACKGROUND: Mushroom polysaccharides play an important role in functional foods because they exhibit biological modulator properties such as antitumour, antiviral and antibacterial activities. The present study involved the production, purification and characterisation of intracellular and extracellular free and protein-bound polysaccharides from Pleurotus ostreatus and the investigation of their growth-inhibitory effect on human carcinoma cell lines. RESULTS: Several fermentation parameters were obtained: batch polysaccharide productivities of 0.013 ± 8.12 × 10⁻5 and 0.037 ± 0.0005 g L⁻¹ day⁻¹ for intracellular and extracellular polysaccharides respectively, a maximum biomass concentration of 9.35 ± 0.18 g L⁻¹ , P(max) = 0.935 ± 0.018 g L⁻¹ day⁻¹, µ(max) = 0.218 ± 0.02 day⁻¹, Y(EP/X) = 0.040 ± 0.0015 g g⁻¹ and Y(IP/X) = 0.014 ± 0.0003 g g⁻¹ . Some polysaccharides exhibited superoxide dismutase (SOD)-like activity of 50-200 units. Fourier transform infrared analysis of the polysaccharides revealed absorption bands characteristic of such biological macromolecules. Cytotoxicity assays showed that both intracellular and extracellular polysaccharides exhibited antitumour activity towards several tested human carcinoma cell lines in a dose-dependent manner. CONCLUSION: The polysaccharides of P. ostreatus exhibited high SOD-like activity, which strongly supports their biological effect on tumour cell lines. The extracellular polysaccharides presented the highest antitumour activity towards the RL95 carcinoma cell line and should be further investigated as an antitumour agent.