Pharmacological and cell-based treatments to increase local skin flap viability in animal models.

Local skin flaps are frequently employed for wound closure to address surgical, traumatic, congenital, or oncologic defects. (1) Despite their clinical utility, skin flaps may fail due to inadequate perfusion, ischemia/reperfusion injury (IRI), excessive cell death, and associated inflammatory response. (2) All of these factors contribute to skin flap necrosis in 10-15% of cases and represent a significant surgical challenge. (3, 4) Once flap necrosis occurs, it may require additional surgeries to remove the entire flap or repair the damage and secondary treatments for infection and disfiguration, which can be costly and painful. (5) In addition to employing appropriate surgical techniques and identifying healthy, well-vascularized tissue to mitigate the occurrence of these complications, there is growing interest in exploring cell-based and pharmacologic augmentation options. (6) These agents typically focus on preventing thrombosis and increasing vasodilation and angiogenesis while reducing inflammation and oxidative stress. Agents that modulate cell death pathways such as apoptosis and autophagy have also been investigated. (7) Implementation of drugs and cell lines with potentially beneficial properties have been proposed through various delivery techniques including systemic treatment, direct wound bed or flap injection, and topical application. This review summarizes pharmacologic- and cell-based interventions to augment skin flap viability in animal models, and discusses both translatability challenges facing these therapies and future directions in the field of skin flap augmentation.

The association between frailty and survival in patients with pleural disease: a retrospective cohort study.

BACKGROUND: There are currently no data on the relationship between frailty and mortality in pleural disease. Understanding the relationship between frailty and outcomes is increasingly important for clinicians to guide decisions regarding investigation and management. This study aims to explore the relationship between all-cause mortality and frailty status in patients with pleural disease. METHODS: In this retrospective analysis of a prospectively collected observational cohort study, outpatients presenting to the pleural service at a tertiary centre in Bristol, UK with a radiologically confirmed, undiagnosed pleural effusion underwent comprehensive assessment and were assigned a final diagnosis at 12 months. The modified frailty index (mFI) was calculated and participants classified as frail (mFI ≥ 0.4) or not frail (mFI ≤ 0.2). RESULTS: 676 participants were included from 3rd March 2008 to 29th December 2020. The median time to mortality was 490 days (IQR 161-1595). A positive association was found between 12-month mortality and frailty (aHR = 1.72, 95% CI 1.02-2.76, p = 0.025) and age ≥ 80 (aHR = 1.80, 95% CI 1.24-2.62, p = 0.002). Subgroup analyses found a stronger association between 12-month mortality and frailty in benign disease (aHR = 4.36, 95% CI 2.17-8.77, p < 0.0001) than in all pleural disease. Malignancy irrespective of frailty status was associated with an increase in all-cause mortality (aHR = 10.40, 95% CI 6.01-18.01, p < 0.0001). CONCLUSION: This is the first study evaluating the relationship between frailty and outcomes in pleural disease. Our data demonstrates a strong association between frailty and 12-month mortality in this cohort. A malignant diagnosis is an independent predictor of 12-month mortality, irrespective of frailty status. Frailty was also strongly associated with 12-month mortality in patients with a benign underlying cause for their pleural disease. This has clinical relevance for pleural physicians; evaluating patients' frailty status and its impact on mortality can guide clinicians in assessing suitability for invasive investigation and management. TRIAL REGISTRATION: This study is registered with the Health Research Authority (REC reference 08/H0102/11) and the NIHR Portfolio (Study ID 8960).

Effects of Unilateral High Frequency Stimulation of the Subthalamic Nucleus on Risk-avoidant Behavior in a Partial 6-hydroxydopamine Model of Parkinson's Disease.

BACKGROUND: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a well-established treatment for the motor symptoms of Parkinson's disease (PD). While PD is primarily characterized by motor symptoms such as tremor, rigidity, and bradykinesia, it also involves a range of non-motor symptoms, and anxiety is one of the most common. The relationship between PD and anxiety is complex and can be a result of both pathological neural changes and the psychological and emotional impacts of living with a chronic progressive condition. Managing anxiety in PD is critical for improving the patients' quality of life. However, patients undergoing STN DBS can occasionally experience increased anxiety. METHODS: This study investigates changes in risk-avoidant behavior following STN DBS in a pre-motor animal model of PD under chronic and acute unilateral high frequency stimulation. RESULTS: No significant changes in risk-avoidant behaviors were observed in rats who underwent STN DBS compared with sham stimulation controls. Chronic stimulation prevented sensitization in the elevated zero maze. CONCLUSIONS: These results suggest that unilateral stimulation of the STN may have minimal effects on risk-avoidant behaviors in PD. However, additional research is required to fully understand the mechanisms responsible for changes in anxiety during STN DBS for PD.

Temperature effects on neuronal synchronization in seizures.

We present a computational model of networked neurons developed to study the effect of temperature on neuronal synchronization in the brain in association with seizures. The network consists of a set of chaotic bursting neurons surrounding a core tonic neuron in a square lattice with periodic boundary conditions. Each neuron is reciprocally coupled to its four nearest neighbors via temperature dependent gap junctions. Incorporating temperature in the gap junctions makes the coupling stronger when temperature rises, resulting in higher likelihood for synchrony in the network. Raising the temperature eventually makes the network elicit waves of synchronization in circular ripples that propagate from the center outwardly. We suggest this process as a possible underlying mechanism for seizures induced by elevated brain temperatures.

What does visual snow look like? Quantification by matching a simulation.

The primary symptom of visual snow syndrome (VSS) is the unremitting perception of small, flickering dots covering the visual field. VSS is a serious but poorly understood condition that can interfere with daily tasks. Several studies have provided qualitative data about the appearance of visual snow, but methods to quantify the symptom are lacking. Here, we developed a task in which participants with VSS adjusted parameters of simulated visual snow on a computer monitor until the simulation matched their internal visual snow. On each trial, participants (n = 31 with VSS) modified the size, density, update speed, and contrast of the simulation. Participants' settings were highly reliable across trials (intraclass correlation coefficients > 0.89), and they reported that the task was effective at stimulating their visual snow. On average, visual snow was very small (less than 2 arcmin in diameter), updated quickly (mean temporal frequency = 18.2 Hz), had low density (mean snow elements vs. background = 2.87%), and had low contrast (average root mean square contrast = 2.56%). Our task provided a quantitative assessment of visual snow percepts, which may help individuals with VSS communicate their experience to others, facilitate assessment of treatment efficacy, and further our understanding of the trajectory of symptoms, as well as the neural origins of VSS.

Natural Compounds and Biomimetic Engineering to Influence Fibroblast Behavior in Wound Healing.

Throughout history, natural products have played a significant role in wound healing. Fibroblasts, acting as primary cellular mediators in skin wound healing, exhibit behavioral responses to natural compounds that can enhance the wound healing process. Identifying bioactive natural compounds and understanding their impact on fibroblast behavior offers crucial translational opportunities in the realm of wound healing. Modern scientific techniques have enabled a detailed understanding of how naturally derived compounds modulate wound healing by influencing fibroblast behavior. Specific compounds known for their wound healing properties have been identified. Engineered biomimetic compounds replicating the natural wound microenvironment are designed to facilitate normal healing. Advanced delivery methods operating at micro- and nano-scales have been developed to effectively deliver these novel compounds through the stratum corneum. This review provides a comprehensive summary of the efficacy of natural compounds in influencing fibroblast behavior for promoting wound regeneration and repair. Additionally, it explores biomimetic engineering, where researchers draw inspiration from nature to create materials and devices mimicking physiological cues crucial for effective wound healing. The review concludes by describing novel delivery mechanisms aimed at enhancing the bioavailability of natural compounds. Innovative future strategies involve exploring fibroblast-influencing pathways, responsive biomaterials, smart dressings with real-time monitoring, and applications of stem cells. However, translating these findings to clinical settings faces challenges such as the limited validation of biomaterials in large animal models and logistical obstacles in industrial production. The integration of ancient remedies with modern approaches holds promise for achieving effective and scar-free wound healing.

Effects of supplementing milk replacer with essential amino acids on blood metabolites, immune response, and nitrogen metabolism of Holstein calves exposed to an endotoxin.

This study evaluated the effects of supplementing calf milk replacer with essential AA on immune responses, blood metabolites, and nitrogen metabolism of 32 Holstein bull calves [28 d of age, 44 ± 0.8 kg of body weight (BW)] exposed to lipopolysaccharide (LPS). Calves were bottle-fed a commercial milk replacer (20% crude protein and 20% fat, dry matter basis) twice daily along with a calf starter (19% crude protein, dry matter basis) for 45 d. The experiment was a randomized complete block design and treatments were a 2 × 2 factorial arrangement. Treatments were milk replacer (fed twice daily at 0.5 kg/d of powder) supplemented with or without 10 essential AA (+AA vs. -AA), and subcutaneous injection of sterile saline with or without LPS (+LPS vs. -LPS) at 3 h after the morning feeding on d 15 (4 µg LPS per kg of BW) and 17 (2 µg LPS per kg of BW). Calves also received a 2-mL subcutaneous injection of ovalbumin (6 mg of ovalbumin/mL) on d 16 and 30. Rectal temperature and blood samples were collected on d 15 before LPS injection and at h 4, 8, 12, and 24 thereafter. From d 15 to 19, total fecal and urinary output were collected, and feed refusals were documented. Rectal temperature was greater in +LPS than -LPS calves at h 4, 8, and 12 after LPS injection. Serum cortisol was greater for +LPS than -LPS at h 4 after LPS exposure. At d 28, serum antiovalbumin IgG level was greater in +LPS +AA calves compared with +LPS -AA. Serum glucose was lower for +LPS than -LPS at h 4 and 8. Serum insulin was greater in +LPS than -LPS calves. Plasma concentrations of Thr, Gly, Asn, Ser, and hydroxyproline were lower for +LPS versus -LPS calves. Plasma concentrations of Met, Leu, Phe, His, Ile, Trp, Thr, and Orn were greater in +AA calves than -AA calves. Plasma urea N and N retention were not different among LPS and AA treatments. The lower concentrations of AA in +LPS than -LPS calves indicate higher demand for AA in immuno-compromised calves fed milk replacer. Additionally, higher concentration of ovalbumin-specific IgG level in +LPS calves supplemented with +AA compared with +LPS calves with -AA suggests that supplementing AA to immune-compromised calves might improve immune status.

Post-chemotherapy and targeted therapy imaging of the chest in lung cancer.

Non-small-cell lung cancer (NSCLC) is frequently diagnosed when it is not amenable to local therapies; therefore, systemic agents are the mainstay of therapy for many patients. In recent years, treatment of advanced NSCLC has evolved from a general approach primarily involving chemotherapy to a more personalised strategy in which biomarkers such as the presence of genomic tumour aberrations and the expression of immune proteins such as programmed death-ligand 1 (PD-L1), in combination with other elements of clinical information such as histology and clinical stage, guide management. For instance, pathways resulting in uncontrolled growth and proliferation of tumour cells due to epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) rearrangements may be targeted by tyrosine kinase inhibitors (TKIs). In this article, we review the current state of medical oncology, imaging characteristics of mutations, pitfalls in response assessments and the imaging of complications.

Post-immunotherapy imaging in lung cancer.

By boosting the immune system, immunotherapy with immune checkpoint inhibitors (ICIs) has altered the management of patients with various cancers including those with metastatic non-small cell lung cancer (NSCLC). As a result of immune system activation, ICIs are associated with unique response patterns (that are not addressed by traditional response criteria) and inflammatory side effects termed immune-related adverse events. In this article, we will review the role of immunotherapy in cancer treatment, specifically ICIs used in NSCLC treatment, radiological response criteria of immunotherapy, and the imaging spectrum of immune-related adverse events.

Children's perceptions of fluid milk with varying levels of milkfat.

Schools participating in federal meal programs are limited to serving skim or low-fat (≤1%) flavored and unflavored milk. Few studies have directly addressed child perceptions and preferences for milk containing different amounts of milkfat. The objective of this study was to determine whether children can differentiate between flavored and unflavored fluid milk containing varying levels of milkfat and whether preferences for certain levels of milkfat exist. Flavored and unflavored milks containing 4 different percentages of milkfat (≤0.5, 1, 2, and 3.25%) were high-temperature, short-time processed, filled into half-gallon light-shielded milk jugs, and stored at 4°C in the dark. Milks were evaluated by children (ages 8-13 yr) following 7 d at 4°C. Acceptance testing and tetrad difference testing were conducted on flavored and unflavored milks with and without visual cues to determine if differences were driven by visual or flavor or mouthfeel cues. Child acceptance testing (n = 138 unflavored; n = 123 flavored) was conducted to evaluate liking and perception of selected attributes. Tetrad testing (n = 127 unflavored; n = 129 flavored) was conducted to determine if children could differentiate between different fat levels even in the absence of a difference in acceptance. The experiment was replicated twice. When visual cues were present, children had higher overall liking for 1% and 2% milks than skim for unflavored milk and higher liking for chocolate milks containing at least 1% milk fat than for skim. Differences in liking were driven by appearance, viscosity, and flavor. In the absence of visual cues, no differences were observed in liking or flavor or mouthfeel attributes for unflavored milk but higher liking for at least 1% milk fat in chocolate milk compared with skim was consistent with the presence of visual cues. From tetrad testing, children could visually tell a difference between all unflavored pairs except 2% versus whole milk and could not detect consistent differences between milkfat pairs in the absence of visual cues. For chocolate milk, children could tell a difference between all milk fat pairs with visual cues and could tell a difference between skim versus 2% and skim versus whole milk without visual cues. These results demonstrate that in the absence of package-related flavors, school-age children like unflavored skim milk as well as milk with higher fat content in the absence of visual cues. In contrast, appearance as well as flavor and mouthfeel attributes play a role in children's liking as well as their ability to discriminate between chocolate milks containing different amounts of fat, with chocolate milk containing at least 1% fat preferred. The sensory quality of school lunch milk is vital to child preference, and processing efforts are needed to maximize school milk sensory quality.

Effects of micellar casein concentrate purity and milk fat on sulfur/eggy flavor in ultrapasteurized milk-based beverages.

Our objectives were to determine the level of milk-derived whey protein (MDWP) removal necessary to achieve no detectable sulfur/eggy flavor in ultrapasteurized fat-free micellar casein concentrate (MCC) beverages (6.5% protein) and in the same beverages containing 1 and 2% milk fat. Micellar casein concentrate with 95% MDWP removal was produced from skim milk (50°C) with a 3×, 3-stage ceramic microfiltration (MF) process using 0.1-µm pore size graded permeability membranes (n = 3). In experiment 1, MCC-based beverages at about 6.5% (wt/wt) true protein were formulated at a fat content of 0.15% fat (wt/wt) at 4 different levels of MDWP removal percentages (95.2%, 91.0%, 83.2%, and 69.3%). In experiment 2, a similar series of beverages at 3 MDWP removal percentages (95.2%, 83.2%, and 69.3%) with 0.1, 1, and 2% fat content were produced. The purity (or completeness of removal of whey protein by MF) of MCC was determined by the Kjeldahl method and sodium dodecyl sulfate (SDS)-PAGE. Sensory properties of beverages were documented by descriptive sensory analysis, and volatile sulfur compounds were evaluated using solid-phase microextraction followed by gas chromatography-triple quadrupole mass spectrometry. The purity of MCC measured by the Kjeldahl method (casein as a percentage of true protein) was higher after thermal treatment than before, whereas MCC purity evaluated by SDS-PAGE was unchanged by heat treatment. The purity of MCC had an effect on the flavor profile of thermally processed beverages at 6.5% protein made with fresh liquid MCC. No sulfur/eggy flavor was detected in MCC beverages when 95% of the MDWP was removed (MCC purity about 93 to 94%) from skim milk by microfiltration at 0.1, 1, and 2% fat. As the fat content of 6.5% protein beverages produced with MCC increased, sulfur/eggy flavor intensity and hydrogen sulfide concentration decreased. However, the effect of increasing milk fat on reducing sulfur/eggy flavor in MCC-based beverages at 6.5% protein was less than that of increasing MDWP removal from MCC. Sulfur off-flavors in neutral-pH dairy protein beverages can be mitigated by use of high-purity MCC or by incorporation of fat in the beverage, or both.

Germline ATM variants predispose to melanoma: a joint analysis across the GenoMEL and MelaNostrum consortia.

PURPOSE: Ataxia-Telangiectasia Mutated (ATM) has been implicated in the risk of several cancers, but establishing a causal relationship is often challenging. Although ATM single-nucleotide polymorphisms have been linked to melanoma, few functional alleles have been identified. Therefore, ATM impact on melanoma predisposition is unclear. METHODS: From 22 American, Australian, and European sites, we collected 2,104 familial, multiple primary (MPM), and sporadic melanoma cases who underwent ATM genotyping via panel, exome, or genome sequencing, and compared the allele frequency (AF) of selected ATM variants classified as loss-of-function (LOF) and variants of uncertain significance (VUS) between this cohort and the gnomAD non-Finnish European (NFE) data set. RESULTS: LOF variants were more represented in our study cohort than in gnomAD NFE, both in all (AF = 0.005 and 0.002, OR = 2.6, 95% CI = 1.56-4.11, p < 0.01), and familial + MPM cases (AF = 0.0054 and 0.002, OR = 2.97, p < 0.01). Similarly, VUS were enriched in all (AF = 0.046 and 0.033, OR = 1.41, 95% CI = 1.6-5.09, p < 0.01) and familial + MPM cases (AF = 0.053 and 0.033, OR = 1.63, p < 0.01). In a case-control comparison of two centers that provided 1,446 controls, LOF and VUS were enriched in familial + MPM cases (p = 0.027, p = 0.018). CONCLUSION: This study, describing the largest multicenter melanoma cohort investigated for ATM germline variants, supports the role of ATM as a melanoma predisposition gene, with LOF variants suggesting a moderate-risk.

Ataxia and mobility in children following surgical resection of posterior fossa tumour: A longitudinal cohort study.

PURPOSE: To report the course of ataxia in children up to 2 years post-operatively, following surgical resection of a posterior fossa tumour (PFT). METHODS: Thirty-five children, (median age 9 years, range 4-15) having resection of PFT, were assessed using the Scale for the Assessment and Rating of Ataxia (SARA), Brief Ataxia Rating Scale (BARS) and the mobility domain of the Paediatric Evaluation of Disability Index (PEDI-m) at initial post-operative period (baseline), 3 months, 1 year and 2 years post-operatively. RESULTS: Baseline median scores of the SARA and BARS were 8.5 (range 0-35.5), and 7 (0-25) respectively. Ataxia improved at 3 months (median SARA and BARS reduction 3.5 and 4, respectively). Additional gradual improvements in SARA were recorded at 1 (median reduction 2) and 2 years post-operatively (median reduction 0.5). Median baseline PEDI-m was 54.75 (range 15.2-100) with improvement at 3 months (median increase 36.95) and small improvement at 1 year (median increase 2.5) and 2 years (median increase 5.8). Children with medulloblastoma and midline tumours (median baseline SARA 10 and 11, respectively) demonstrated more severe ataxia than children with low-grade gliomas and unilateral tumours (median baseline SARA 7.5 and 6.5, respectively). CONCLUSION: The largest improvement in ataxia scores and functional mobility scores is demonstrated within the first 3 months post-operatively, but ongoing gradual improvement is observed at 2 years. Children with medulloblastoma and midline tumour demonstrated higher ataxia scores long term.

Invited review: Microfiltration-derived casein and whey proteins from milk.

Milk, a rich source of nutrients, can be fractionated into a wide range of components for use in foods and beverages. With advancements in filtration technologies, micellar caseins and milk-derived whey proteins are now produced from skim milk using microfiltration. Microfiltered ingredients offer unique functional and nutritional benefits that can be exploited in new product development. Microfiltration offers promise in cheesemaking, where microfiltered milk can be used for protein standardization to improve the yield and consistency of cheese and help with operation throughputs. Micellar casein concentrates and milk whey proteins could offer unique functional and flavor properties in various food applications. Consumer desires for safe, nutritious, and clean-label foods could be potential growth opportunities for these new ingredients. The application of micellar casein concentrates in protein standardization could offer a window of opportunity to US cheese makers by improving yields and throughputs in manufacturing plants.

Ready-to-drink protein beverages: Effects of milk protein concentration and type on flavor.

This study evaluated the role of protein concentration and milk protein ingredient [serum protein isolate (SPI), micellar casein concentrate (MCC), or milk protein concentrate (MPC)] on sensory properties of vanilla ready-to-drink (RTD) protein beverages. The RTD beverages were manufactured from 5 different liquid milk protein blends: 100% MCC, 100% MPC, 18:82 SPI:MCC, 50:50 SPI:MCC, and 50:50 SPI:MPC, at 2 different protein concentrations: 6.3% and 10.5% (wt/wt) protein (15 or 25 g of protein per 237 mL) with 0.5% (wt/wt) fat and 0.7% (wt/wt) lactose. Dipotassium phosphate, carrageenan, cellulose gum, sucralose, and vanilla flavor were included. Blended beverages were preheated to 60°C, homogenized (20.7 MPa), and cooled to 8°C. The beverages were then preheated to 90°C and ultrapasteurized (141°C, 3 s) by direct steam injection followed by vacuum cooling to 86°C and homogenized again (17.2 MPa first stage, 3.5 MPa second stage). Beverages were cooled to 8°C, filled into sanitized bottles, and stored at 4°C. Initial testing of RTD beverages included proximate analyses and aerobic plate count and coliform count. Volatile sulfur compounds and sensory properties were evaluated through 8-wk storage at 4°C. Astringency and sensory viscosity were higher and vanillin flavor was lower in beverages containing 10.5% protein compared with 6.3% protein, and sulfur/eggy flavor, astringency, and viscosity were higher, and sweet aromatic/vanillin flavor was lower in beverages with higher serum protein as a percentage of true protein within each protein content. Volatile compound analysis of headspace vanillin and sulfur compounds was consistent with sensory results: beverages with 50% serum protein as a percentage of true protein and 10.5% protein had the highest concentrations of sulfur volatiles and lower vanillin compared with other beverages. Sulfur volatiles and vanillin, as well as sulfur/eggy and sweet aromatic/vanillin flavors, decreased in all beverages with storage time. These results will enable manufacturers to select or optimize protein blends to better formulate RTD beverages to provide consumers with a protein beverage with high protein content and desired flavor and functional properties.

Clinical activity of programmed cell death 1 (PD-1) blockade in never, light, and heavy smokers with non-small-cell lung cancer and PD-L1 expression ≥50.

BACKGROUND: Immune checkpoint inhibitors (ICIs) are standard therapies for patients with advanced non-small-cell lung cancer (NSCLC) and a programmed death-ligand 1 (PD-L1) tumor proportion score (TPS) ≥50%. Tumor mutation burden (TMB) also predicts response to ICIs but is often not available in real time for decision making in the first-line setting. Smoking exposure can be a proxy for TMB in NSCLC. The impact of smoking status on efficacy of PD-1 blockade in NSCLC patients with PD-L1 TPS ≥50% has not been well defined. PATIENTS AND METHODS: To investigate the relationship between smoking and activity of ICIs in NSCLC, we retrospectively studied 315 patients with NSCLC and PD-L1 TPS ≥50% at five USA academic medical centers. Objective response rates (ORRs), progression-free survival (PFS), and duration of response (DOR) were compared between never (<100 lifetime cigarettes), light (≤10 pack-years), and heavy (>10 pack-years) smokers. A subset of patients underwent next-generation sequencing to estimate TMB. RESULTS: We identified 36 (11%) never, 42 (13%) light, and 237 (75%) heavy smokers with NSCLC and PD-L1 TPS ≥50% treated with ICIs. Objective responses were observed in 27%, 40%, and 40% of never, light, and heavy smokers, respectively (P = 0.180 never versus heavy; P = 1.000 light versus heavy). Median PFS and median DOR were numerically shorter in never and light smokers compared with heavy smokers (PFS 3.0 versus 4.0 versus 5.4 months; median DOR 6.9 versus 10.8 versus 17.8 months), but were not statistically different [PFS: hazard ratio (HR) 1.37, P = 0.135 and HR 1.24, P = 0.272; DOR: HR 1.92, P = 0.217 and HR 1.79, P = 0.141]. CONCLUSIONS: PD-(L)1 inhibitors are associated with antitumor activity in NSCLC with PD-L1 TPS ≥50% regardless of smoking status. Nevertheless, there is a signal of potentially decreased durability among never and light smokers that should be further evaluated. Distinct immunobiologic features may affect initial response versus durability of antitumor immunity to programmed cell death 1 (PD-1) blockade.

Increased care at discharge from COVID-19: The association between pre-admission frailty and increased care needs after hospital discharge; a multicentre European observational cohort study.

BACKGROUND: The COVID-19 pandemic has placed significant pressure on health and social care. Survivors of COVID-19 may be left with substantial functional deficits requiring ongoing care. We aimed to determine whether pre-admission frailty was associated with increased care needs at discharge for patients admitted to hospital with COVID-19. METHODS: Patients were included if aged over 18 years old and admitted to hospital with COVID-19 between 27 February and 10 June 2020. The Clinical Frailty Scale (CFS) was used to assess pre-admission frailty status. Admission and discharge care levels were recorded. Data were analysed using a mixed-effects logistic regression adjusted for age, sex, smoking status, comorbidities, and admission CRP as a marker of severity of disease. RESULTS: Thirteen hospitals included patients: 1671 patients were screened, and 840 were excluded including, 521 patients who died before discharge (31.1%). Of the 831 patients who were discharged, the median age was 71 years (IQR, 58-81 years) and 369 (44.4%) were women. The median length of hospital stay was 12 days (IQR 6-24). Using the CFS, 438 (47.0%) were living with frailty (≥ CFS 5), and 193 (23.2%) required an increase in the level of care provided. Multivariable analysis showed that frailty was associated with an increase in care needs compared to patients without frailty (CFS 1-3). The adjusted odds ratios (aOR) were as follows: CFS 4, 1.99 (0.97-4.11); CFS 5, 3.77 (1.94-7.32); CFS 6, 4.04 (2.09-7.82); CFS 7, 2.16 (1.12-4.20); and CFS 8, 3.19 (1.06-9.56). CONCLUSIONS: Around a quarter of patients admitted with COVID-19 had increased care needs at discharge. Pre-admission frailty was strongly associated with the need for an increased level of care at discharge. Our results have implications for service planning and public health policy as well as a person's functional outcome, suggesting that frailty screening should be utilised for predictive modelling and early individualised discharge planning.

Association between preadmission frailty and care level at discharge in older adults undergoing emergency laparotomy.

BACKGROUND: Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge. METHODS: The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level. RESULTS: A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit. CONCLUSION: Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.

ANTECEDENTES: Los adultos mayores sometidos a cirugía abdominal de urgencia tienen resultados significativamente peores que los adultos jóvenes. Para aquellos pacientes que sobreviven, el nivel de atención que requieren tras el alta hospitalaria se desconoce y esta información podría servir de guía en la toma de decisiones. El estudio ELF (Emergency Laparotomy and Frailty) tenía como objetivo determinar si la fragilidad preoperatoria en adultos mayores se asociaba con un aumento de la dependencia en el momento del alta. MÉTODOS: El estudio ELF era un estudio multicéntrico extenso efectuado en el Reino Unido (n = 49) que incluyó una cohorte prospectiva de 934 pacientes mayores (> 65 años) sometidos a laparotomía de urgencia durante marzo-junio de 2017. El objetivo fue establecer si la fragilidad preoperatoria aumentaba el nivel de asistencia en el momento del alta en comparación con el nivel de asistencia preoperatorio. Para el análisis se utilizó una regresión logística multinivel ajustada a características previas al ingreso: fragilidad, edad del paciente, género, y nivel de asistencia. RESULTADOS: La edad media de los pacientes fue 76,2 años (DE = 6,83), con un 57% de mujeres, un 20,2% de pacientes frágiles y un 37,4% de adultos mayores que presentaron un aumento en el nivel de asistencia en el momento del alta. Un aumento de la fragilidad se asoció con un incremento en el nivel de asistencia en el momento del alta (y mayor poder predictivo que la edad). La razón de oportunidades (odds ratio, OR) ajustada por el aumento del nivel de asistencia fue 4,48 (i.c. del 95% 2,03-9,91) para pacientes aparentemente vulnerables (Clinical Frailty Scale, CFS 4); 5,94 (i.c. del 95% 2,54-13,90) para aquellos ligeramente frágiles (CFS 5); y 7,88 (i.c. del 95% 2,97-20,79) para aquellos con fragilidad moderada o grave (CFS 6 and 7) en comparación con pacientes en buenas condiciones. CONCLUSIÓN: Este es el primer estudio que documenta que más del 37% de adultos mayores sometidos a laparotomía de urgencia precisaron un aumento en el nivel de asistencia en el momento del alta. La evaluación de la fragilidad debería integrarse en todas las unidades quirúrgicas de agudos para ayudar a compartir la toma de decisiones y los planes de tratamiento.

Risk factors for incident delirium among urological patients: a systematic review and meta-analysis with GRADE summary of findings.

BACKGROUND: Post-operative delirium is an important, yet under-researched complication of surgery. Patients undergoing urological surgery may be at especially high risk of POD, as they are often older, and interventions can be associated with conditions that trigger delirium. The main aim of this systematic review was to evaluate the available evidence for risk factors in this patient group. METHODS: Five databases were searched (MEDLINE, Web of Science, EMBASE, CINAHL and PsychInfo) between January 1987 and June 2019. The Newcastle-Ottawa Scale was used to assess for risk of bias. Pooled odds ratio or mean difference (MD) for individual risk factors were estimated using the Mantel-Haenzel and inverse variance methods. RESULTS: Seven articles met the inclusion criteria, giving a total population of 1937. The incidence of POD ranged from 5 to 29%. Three studies were deemed low risk of bias and four at a high risk of bias. Nine risk factors were suitable for meta-analysis, with age (MD 4.314 95% CI 1.597, 7.032 p = 0.002) and the clock drawing test (MD - 2.443 95% CI - 3.029, - 1.857 p < 0.001) having a statistically significant association with POD in pooled analyses. CONCLUSION: Delirium is common in urological patients. This review has identified a lack of studies in this surgical population, with wide heterogeneity and high risk of bias. It also highlights a number of potential risk factors for post-operative delirium, of which some are modifiable. However, the strength of evidence is weak at present and so future research should focus on assessing comparable risk factors in this patient group in order to inform future clinical practice. Review registration The review protocol was prospectively registered with the PROSPERO database (reference CRD42017054613).

Invited review: Astringency in whey protein beverages.

Astringency is the sensation of mouth drying and puckering, and it has also been described as a loss of lubrication in the mouth. Astringency is perceived as an increase in oral friction or roughness. Astringency caused by tannins and other polyphenols has been well documented and studied. Whey proteins are popular for their functional and nutritional quality, but they exhibit astringency, particularly under acidic conditions popular in high acid (pH 3.4) whey protein beverages. Acids cause astringency, but acidic protein beverages have higher astringency than acid alone. Whey proteins are able to interact with salivary proteins, which removes the lubricating saliva layer of the mouth. Whey proteins can also interact directly with epithelial tissue. These various mechanisms of astringency limit whey protein ingredient applications because astringency is undesirable to consumers. A better understanding of the causes of whey protein astringency will improve our ability to produce products that have high consumer liking and deliver excellent nutrition.