Research gaps and priorities for quantitative microbial risk assessment (QMRA).

The coronavirus disease 2019 pandemic highlighted the need for more rapid and routine application of modeling approaches such as quantitative microbial risk assessment (QMRA) for protecting public health. QMRA is a transdisciplinary science dedicated to understanding, predicting, and mitigating infectious disease risks. To better equip QMRA researchers to inform policy and public health management, an Advances in Research for QMRA workshop was held to synthesize a path forward for QMRA research. We summarize insights from 41 QMRA researchers and experts to clarify the role of QMRA in risk analysis by (1) identifying key research needs, (2) highlighting emerging applications of QMRA; and (3) describing data needs and key scientific efforts to improve the science of QMRA. Key identified research priorities included using molecular tools in QMRA, advancing dose-response methodology, addressing needed exposure assessments, harmonizing environmental monitoring for QMRA, unifying a divide between disease transmission and QMRA models, calibrating and/or validating QMRA models, modeling co-exposures and mixtures, and standardizing practices for incorporating variability and uncertainty throughout the source-to-outcome continuum. Cross-cutting needs identified were to: develop a community of research and practice, integrate QMRA with other scientific approaches, increase QMRA translation and impacts, build communication strategies, and encourage sustainable funding mechanisms. Ultimately, a vision for advancing the science of QMRA is outlined for informing national to global health assessments, controls, and policies.

Commentary on packing vs non-packing of pilonidal sinus cavities after incision and drainage.

Pilonidal sinus disease (PSD) manifests as an inflammatory skin condition typically emerging within the anal cleft. The prevalence of this disease varies in high income countries. This disease is associated with significant physical and psychosocial distress. Surgery is an option for managing PSD; yet, surgical methods vary, and a universally accepted gold standard approach is lacking, leading to current practices that are diverse and subject to ongoing debate. One such point of contention revolves around the decision to use packing or opt for a non-packing approach following surgery. Mohamedahmed et al (2021) conducted a systematic review to evaluate the comparative outcomes of packing versus non-packing of an abscess cavity following incision and drainage of cutaneous abscess on any part of the body. This commentary aims to critically appraise the methods used within the review by Mohamedahmed et al (2021) and expand upon the findings in the context of treatment and management of PSD.

How common is dysphagia in older adults living at home and what are the potential risk factors?

Dysphagia, or difficulty swallowing food or drink, can lead to poorer health outcomes and serious complications such as aspiration pneumonia. Dysphagia can often go undetected and is known to be common amongst hospitalised older adults and those living in institutional care. Less is known about the prevalence of dysphagia amongst older adults who live at home. This commentary critically appraises a systematic review that determines prevalence rates and risk factors for dysphagia in the community-dwelling elderly.

Developing an understanding of the risk factors for falls among adults with intellectual disabilities: a commentary.

Commentary on: Pope J, Truesdale M, Brown M. Risk factors for falls among adults with intellectual disabilities: A narrative review. J Appl Res Intellect Disabil. 2021; 34: 274-285. 10.1111/jar.12805 Falls are a serious and common problem for people with intellectual disabilities (ID). Whilst there is available evidence on falls risk factors for the general population, there is a lack of awareness and understanding of the contributing risk factors for this population. This commentary critically appraises a recent narrative review which sought to identify the risk factors for falls among people with ID. Clinical practice implications: Community nurses may identify people with ID at risk of falls, and work alongside other healthcare professionals and carers to provide tailored multidisciplinary falls-prevention interventions for individuals with ID living in the community.

Cognitive frailty in older adults with diabetes: prevalence and risk factors.

In older adults living with diabetes, there is a higher prevalence of frailty and a greater risk of cognitive impairment. Cognitive frailty is defined by the presence of both and is associated with an increased risk of mortality. A systematic review was undertaken to estimate the prevalence of cognitive frailty in community-dwelling older adults living with diabetes and associated risk factors. This commentary critically appraises the review and explores the implications of the findings for community practice.

Effectiveness of mobility training for frail older adults living in the community.

Frailty in older adults is a major health concern for individuals, families and society. Increasing physical activity helps to reduce frailty in older adults and improve health outcomes. Mobility is also essential to independence and well-being in older adults. A systematic review was undertaken to explore the impact of mobility training on older persons living with frailty in the community. This commentary critically appraises the review and explores the implications for practice.

Non-pharmacological interventions for managing pain in community-dwelling older adults.

Pain is a complex and common issue within older adults. This complexity can be a direct result of comorbidities and the subsequent polypharmacy. The effective control of pain in older adults needs more than just pharmacological management. Non-pharmacological interventions have been demonstrated to be beneficial when combined with pain medications. This commentary critically appraises a systematic review that examines the effectiveness of non-pharmacological interventions for the management of pain in community dwelling older adults.

Cost effectiveness of fall prevention programmes for older adults.

Falls are associated with a substantial increase in risk of mortality and are the second leading cause of unintentional death worldwide. A single fall can affect all aspects of an older person's life. These broad impacts can lead to worse disability outcomes and a higher likelihood of long-term nursing home admission. There is a need to identify not just effective falls prevention interventions but also cost effectiveness.

The prevalence of comorbidity in rheumatoid arthritis: a systematic review and meta-analysis.

This systematic review and meta-analysis estimates the prevalence of common comorbid health disorders in adults with rheumatoid arthritis (RA). A multi-database search strategy was undertaken. Screening, data extraction and quality assessment were carried out by two independent reviewers. A meta-analysis and meta-regression were used to generate a pooled prevalence estimate and identify relevant moderators. After study selection, 33 studies (74633 participants) were included in the meta-analysis. Some 31 studies were judged to be of low risk of bias, and two studies were judged to be at moderate risk of bias. The three most common comorbidities in RA were anxiety disorders (62.1%, 95% Cl: 43.6%; 80.6%), hypertension (37.7%, 95% Cl: 29.2%; 46.2%) and depression (32.1%, 95% Cl: 21.6%; 42.7%). There was substantial statistically significant heterogeneity for all comorbidities (I2 ≥77%). Meta-regression identified that the covariate of mean age (unit increase) had a statistically significant effect on the prevalence of hypertension (+2.3%, 95% Cl: 0.4%; 4.2%), depression (-0.5%, 95% Cl: -0.6%; -0.4%) and cancer (0.5%, 95% Cl: 0.2%; 0.8%) in adults with RA. A country's income was identified to have a statistically significant effect on the prevalence of depression, with low-to moderate-income countries having 40% (95% Cl: 14.0%; 66.6%) higher prevalence than high-income countries. No studies consider health inequalities. It is concluded that comorbidities are prevalent among people with RA, particularly those associated with mental health and circulatory conditions. Provision of health services should reflect the importance of such multimorbidity and the consequences for quality and length of life.

Stroke survivors' and carers' experiences of a systematic voiding programme to treat urinary incontinence after stroke.

AIMS AND OBJECTIVES: To explore the views and experiences of stroke survivors and carers about a systematic voiding programme for poststroke incontinence. BACKGROUND: Urinary incontinence after stroke is common and associated with poorer functional outcome. Structured assessment and management are potentially effective interventions, but it is important that there is a good understanding of stroke survivors' and carers' views of their acceptability and implementation. DESIGN: A qualitative study within a feasibility trial. METHODS: Sixteen participants (12 stroke survivors and four carers) were interviewed using a structured schedule shortly before discharge from one of six inpatient stroke units across six hospitals. Interviews were audio-recorded and transcribed verbatim, and thematic analysis was conducted. FINDINGS: Participants included seven male and five female stroke survivors (mean age 76 years) and four female carers (two wives and two daughters). Themes relating to the preliminary (assessment) phase of the programme were as follows: physical impact, psychological impact, beliefs about incontinence, and the assessment process itself. Main themes relating to the implementation of the programme included the following: timed voiding decisions, adapting the programme or the timed voiding schedule, and urinary incontinence management techniques. Participants felt that the programme helped them to re-establish a regular pattern of micturition and to regain autonomy. CONCLUSIONS: The effectiveness of a systematic voiding programme may partly lie in its educational component, challenging patients' and carers' assumptions that poststroke incontinence is inevitable. Individual adaptation of the programme and the ability to incorporate it alongside other aspects of care are likely to be key factors influencing implementation. RELEVANCE TO CLINICAL PRACTICE: Urinary incontinence is common after stroke. To maximise benefits from a systematic voiding programme, nurses should support stroke survivors to overturn erroneous beliefs, to participate in tailoring of the programme, and in self-management where appropriate.

Client and clinical staff perceptions of barriers to and enablers of the uptake and delivery of behavioural interventions for urinary incontinence: qualitative evidence synthesis.

AIM: To evaluate factors influencing uptake and delivery of behavioural interventions for urinary incontinence from the perspective of clients and clinical staff. BACKGROUND: Behavioural interventions are recommended as first-line therapy for the management of urinary incontinence. Barriers to and enablers of uptake and delivery of behavioural interventions have not been reviewed. DESIGN: Qualitative evidence synthesis. DATA SOURCES: MEDLINE, EMBASE, CINAHL, PsychInfo, AMED (inception to May 2013); Proceedings of the International Continence Society (ICS) (2006-2013). REVIEW METHODS: Studies where data were collected from clients or staff about their experiences or perceptions of behavioural interventions were included. Two reviewers independently screened records on title and abstract. Full-text papers were obtained for records identified as potentially relevant by either reviewer. Two reviewers independently filtered all full-text papers for inclusion, extracted findings and critically appraised studies. We used an approach akin to Framework, using a matrix of pre-specified themes to classify the data and facilitate its presentation and synthesis. RESULTS: Seven studies involving 200 participants identified clients' views. Findings identified from at least one study of moderate quality included increased fear of accidents and convenience of treatment. Factors enabling participation included realistic goals and gaining control. Six studies involving 427 participants identified staff views. Findings identified from at least one study of moderate quality included staff education and perceptions of treatment effectiveness. Enabling factors included teamwork and experience of success. CONCLUSION: There is little detailed exploration of clients' experiences of, and responses to, behavioural interventions. Evidence for staff relates predominantly to prompted voiding in long-term residential care. Studies of the uptake and delivery of other behavioural interventions in other settings are warranted.

Repetitive task training for improving functional ability after stroke.

BACKGROUND: Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation. OBJECTIVES: Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke. Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of 'dose' of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016). SELECTION CRITERIA: Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal. DATA COLLECTION AND ANALYSIS: Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane 'Risk of bias' tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information. MAIN RESULTS: We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has therefore been rated 'moderate' or 'low' when using the GRADE system. There is low-quality evidence that RTT improves arm function (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) 0.01 to 0.49; 11 studies, number of participants analysed = 749), hand function (SMD 0.25, 95% CI 0.00 to 0.51; eight studies, number of participants analysed = 619), and lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48; five trials, number of participants analysed = 419). There is moderate-quality evidence that RTT improves walking distance (mean difference (MD) 34.80, 95% CI 18.19 to 51.41; nine studies, number of participants analysed = 610) and functional ambulation (SMD 0.35, 95% CI 0.04 to 0.66; eight studies, number of participants analysed = 525). We found significant differences between groups for both upper-limb (SMD 0.92, 95% CI 0.58 to 1.26; three studies, number of participants analysed = 153) and lower-limb (SMD 0.34, 95% CI 0.16 to 0.52; eight studies, number of participants analysed = 471) outcomes up to six months post treatment but not after six months. Effects were not modified by intervention type, dosage of task practice or time since stroke for upper or lower limb. There was insufficient evidence to be certain about the risk of adverse events. AUTHORS' CONCLUSIONS: There is low- to moderate-quality evidence that RTT improves upper and lower limb function; improvements were sustained up to six months post treatment. Further research should focus on the type and amount of training, including ways of measuring the number of repetitions actually performed by participants. The definition of RTT will need revisiting prior to further updates of this review in order to ensure it remains clinically meaningful and distinguishable from other interventions.

Implementing a Systematic Voiding Program for Patients With Urinary Incontinence After Stroke.

We explored health professionals' views of implementing a systematic voiding program (SVP) in a multi-site qualitative process evaluation in stroke services recruited to the intervention arms of a cluster randomized controlled feasibility trial during 2011-2013. We conducted semi-structured group or individual interviews with 38 purposively selected nursing, managerial, and care staff involved in delivering the SVP. Content analysis of transcripts used normalization process theory (NPT) as a pre-specified organization-level exploratory framework. Barriers to implementing the SVP included perceived lack of suitability for some patient groups, patient fear of extending hospital stay, and difficulties with SVP enactment, scheduling, timing, recording, and monitoring. Enablers included the guidance provided by the SVP, patient and relative involvement, extra staff, improved nursing skill and confidence, and experience of success. Three potential mechanisms of consistency, visibility, and individualization linked the SVP process with improvements in outcome, and should be emphasized in SVP implementation.

Selective induction and subcellular distribution of ACONITASE 3 reveal the importance of cytosolic citrate metabolism during lipid mobilization in Arabidopsis.

Arabidopsis thaliana has three genes that encode distinct aconitases (ACO), but little is known about the function of each isoenzyme during plant development. In newly emerged seedlings of Arabidopsis, transcript and protein levels for ACO3 were selectively induced to yield more than 80% of total aconitase activity. Characterization of knockout mutants for each of the three ACOs suggests a major role for only ACO3 in citrate metabolism. The aco3 mutant showed delayed early seedling growth, altered assimilation of [14C]acetate feeding and elevated citrate levels, which were nearly 4-fold greater than in wild-type, aco1 or aco2. However, both ACO1 and ACO2 are active in seedlings as shown by inhibition of aco3 growth by the toxin monofluoroacetate, and altered [14C]acetate assimilation and metabolite levels in aco1 and aco2. Relative levels of fumarate and malate differed between aco2 and aco3, indicating metabolically isolated pools of these metabolites in seedlings. Our inability to enrich ACO protein through mitochondria isolation, and the reduced cytosolic ACO activity of the iron-sulfur centre assembly mutant atm3-1, indicated a cytosolic localization of ACO3 in 3-day-old seedlings. Subsequently, we determined that more than 90% of ACO3 was cytosolic. We conclude that ACO3 is cytosolic in young seedlings and functions in citrate catabolism consistent with the operation of the classic glyoxylate and not direct catabolism of citrate within mitochondria.

Pain and diet: A summary of the evidence for the role of diet modification in chronic pain.

Chronic pain constitutes a significant burden to patients and healthcare systems. For many patients, the only option is to attempt to manage their pain within their daily lives. Here, we review evidence provided by three systematic reviews for the effect of diet and diet supplements on patients' experience of chronic pain.