Associations Between Dehydration, Cognitive Impairment, and Frailty in Older Hospitalized Patients: An Exploratory Study.

HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE INSTRUCTIONS 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must: 1. Read the article, "Associations Between Dehydration, Cognitive Impairment, and Frailty in Older Hospitalized Patients: An Exploratory Study" found on pages 19-27, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until April 30, 2019. CONTACT HOURS This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. ACTIVITY OBJECTIVES 1. Describe the incidence of dehydration in older hospitalized patients. 2. Identify risk and management strategies related to dehydration in older hospitalized patients. DISCLOSURE STATEMENT Neither the planners nor the author have any conflicts of interest to disclose. The current exploratory study (a) assessed the prevalence of dehydration in older adults (age ≤60 years) with and without cognitive impairment (CI) admitted to the hospital; and (b) examined associations between dehydration, CI, and frailty. Forty-four patients participated and dehydration was assessed within 24 hours of admission and at Day 4 or discharge (whichever occurred first). Patients' cognitive function and frailty statuses were assessed using validated instruments. Twenty-seven (61%) patients had CI and 61% were frail. Prevalence of dehydration at admission was 29% (n = 12) and 21% (n = 9) [corrected] at study exit, and dehydration status did not differ according to CI or frailty status. However, within the non-CI group, significantly more frail than fit patients were dehydrated at admission (p = 0.03). Findings indicate dehydration is common among older hospitalized patients and that frailty may increase the risk for dehydration in cognitively intact older adults. [Journal of Gerontological Nursing, 42(5), 19-27.].

Outcome of ventilated infants born at term without major congenital abnormalities.

UNLABELLED: The longer-term outcome of term-born infants without congenital anomalies requiring ventilation in the first 24 h after birth has rarely been reported. Our aims were to determine the mortality and long-term morbidity of such infants and identify risk factors for adverse outcome. The outcomes of 43 of 45 infants born at term consecutively requiring mechanical ventilation were reviewed. The infants had: meconium aspiration syndrome (n = 11), hypoxic ischaemic encephalopathy (HIE) (n = 11), respiratory depression (n = 12), sepsis (n = 5), persistent pulmonary hypertension of the newborn (n = 3) and middle cerebral artery infarction (n = 1). Eleven infants developed seizures (26%), 13 (30%) had abnormal electroencephalograms and 11 (26%) had abnormal MRI scans; 26% had an adverse outcome: six died, and five had severe neurodisability at 2 years. The infants with congenital toxoplasmosis and a middle cerebral artery infarction were excluded from the prediction analysis. In the remaining 41 patients, requirement for anticonvulsants (relative risk, RR = 4.44, 95% CI = 1.48 to 12.70; p = 0.014) and prolonged ventilation (longer than 3 days) (RR 4.83, 95% CI 1.51 to 15.64) predicted adverse outcome. Infants with HIE had an increased risk of adverse outcome (relative risk 5.45, 95% CI 1.01 to 33.85), but an adverse outcome occurred in infants with other diagnoses. CONCLUSION: Mortality and neurodisability at follow-up were common in infants born at term without major congenital anomalies who required mechanical ventilation in the first 24 h after birth, particularly in those who developed seizures requiring treatment and prolonged ventilation.

Sequential proteolytic processing of the capsular Caf1 antigen of Yersinia pestis for major histocompatibility complex class II-restricted presentation to T lymphocytes.

We studied the mechanisms of antigen presentation of CD4 T cell epitopes of the capsular Caf1 antigen of Yersinia pestis using murine bone marrow macrophages as antigen presenting cells and T cell hybridomas specific for major histocompatibility complex (MHC) class II-restricted epitopes distributed throughout the Caf1 sequence. The data revealed diversity in the pathways used and the degrees of antigen processing required depending on the structural context of epitopes within the Caf1 molecule. Two epitopes in the carboxyl-terminal globular domain were presented by newly synthesized MHC class II after low pH-dependent lysosomal processing, whereas an epitope located in a flexible amino-terminal strand was presented by mature MHC class II independent of low pH and with no detectable requirement for proteolytic processing. A fourth epitope located between the two regions of Caf1 showed intermediate behavior. The data are consistent with progressive unfolding and cleavage of rCaf1 from the amino terminus as it traverses the endosomal pathway, the availability of epitopes determining which pool of MHC class II is preferentially loaded. The Caf1 capsular protein is a component of second generation plague vaccines and an understanding of the mechanisms and pathways of MHC class II-restricted presentation of multiple epitopes from this candidate vaccine antigen should inform the choice of delivery systems and adjuvants that target vaccines successfully to appropriate intracellular locations to induce protective immune responses against as wide a T cell repertoire as possible.

Recombinant Salmonella vaccines for biodefence.

There is a requirement for vaccines to protect against pathogens that may be misused for bioterrorism or biowarfare purposes. In particular, biodefence vaccines are required that may be used for safe and easy immunisation of populations and that can rapidly induce mucosal immunity to provide protection at the lung surface against a range of airborne agents. To address this need, recombinant Salmonella vaccines are being developed. In this review, the technologies used, considerations needed, progress made, and future prospects for developing multivalent Salmonella-based vaccines for biodefence are discussed.

Humoral and cell-mediated adaptive immune responses are required for protection against Burkholderia pseudomallei challenge and bacterial clearance postinfection.

Burkholderia pseudomallei, the causative agent of melioidosis, is a gram-negative bacillus endemic to areas of southeast Asia and northern Australia. Presently, there is no licensed vaccine for B. pseudomallei and the organism is refractive to antibiotic therapy. The bacterium is known to survive and multiply inside both phagocytic and nonphagocytic host cells and may be able to spread directly from cell to cell. Current vaccine delivery systems are unlikely to induce the correct immune effectors to stimulate a protective response to the organism. In this study, we have developed a procedure to utilize dendritic cells as a vaccine delivery vector to induce cell-mediated immune responses to B. pseudomallei. Dendritic cells were produced by culturing murine bone marrow progenitor cells in medium containing granulocyte-macrophage colony-stimulating factor and tumor necrosis factor alpha. Purified dendritic cells were pulsed with heat-killed whole-cell B. pseudomallei and used to immunize syngeneic mice. Strong cellular immune responses were elicited by this immunization method, although antibody responses were low. Booster immunizations of either a second dose of dendritic cells or heat-killed B. pseudomallei were administered to increase the immune response. Immunized animals were challenged with fully virulent B. pseudomallei, and protection was demonstrated in those with strong humoral and cell-mediated immunity. These results indicate the importance of both cell-mediated and humoral immune mechanisms in protection against intracellular pathogens.

A Salmonella enterica serovar Typhi vaccine expressing Yersinia pestis F1 antigen on its surface provides protection against plague in mice.

A recombinant strain of attenuated Salmonella enterica serovar Typhi surface-expressing Yersinia pestis F1 antigen was generated by transforming strain BRD1116 (aroA aroC htrA) with plasmid pAH34L encoding the Y. pestis caf operon. BRD1116/pAH34L was stable in vitro and in vivo. An immunisation regimen of two intranasal doses of 1 x 10(8) cfu of BRD1116/pAH34L given intranasally to mice 7 days apart induced the strongest immune response compared to other regimens and protected 13 out of 20 mice from lethal challenge with Y. pestis. Intranasal immunisation of mice constitutes a model for oral immunisation with Salmonella vaccines in humans. Thus, the results demonstrate that attenuated strains of S. enterica serovar Typhi which express Y. pestis F1 antigen may be developed to provide an oral vaccine against plague suitable for use in humans.

Prolonged ventilation and intact survival in very low birth weight infants.

UNLABELLED: A requirement for prolonged ventilation (>28 days) has been associated with a poor outcome in infants. We postulated that in the present population of infants who usually receive antenatal steroids and post-natal surfactant, prolonged ventilation in discrete episodes, i.e. discontinuous intermittent positive pressure ventilation (IPPV), would have a better outcome than a requirement for prolonged ventilation continuously from birth (continuous IPPV) and, in addition, that an abnormal ultrasound scan appearance would be a reliable predictor of poor outcome in infants requiring prolonged ventilation. All very low birth weight (VLBW) infants ventilated for at least 28 days (prolonged ventilation) were identified from a prospectively maintained database. At 1 year of age, neurodevelopmental status was assessed and abnormal neurodevelopmental outcome diagnosed if the infant's Griffiths developmental quotient was at least two standard deviations below the mean and/or they had impairment with disability. Of 417 VLBW infants, 41 required prolonged ventilation (30 continuous and 11 discontinuous). In the continuous IPPV group, 18 and one in the discontinuous IPPV group died or had abnormal neurodevelopmental outcome ( P<0.01). All eight infants with major cranial ultrasound abnormalities died or had abnormal outcome ( P<0.01). CONCLUSION: prolonged ventilation can be associated with intact survival, but not in very low birth weight infants with evidence of significant brain injury.

Colloid infusion in the perinatal period and abnormal neurodevelopmental outcome in very low birth weight infants.

UNLABELLED: In very low birth weight (VLBW) infants, colloid infusion is associated with impaired perinatal lung function and increased oxygen dependency duration. The aim of this study was to determine whether perinatal colloid infusion was associated with abnormal neurodevelopmental outcome. All perinatal fluid input (crystalloid and colloid) given to VLBW infants entered into a randomised trial was recorded. At 1 and/or 2 years, the neurodevelopmental status of VLBW infants was routinely assessed. Of 131 survivors, median gestational age 27 weeks (range 23-33 weeks), 95 were seen at follow-up. Nineteen had abnormal neurodevelopmental outcome and differed significantly from the rest of the cohort with regard to their birth weight, magnitude of colloid infusion received and the proportions who had received postnatal steroids, suffered prolonged oxygen dependency or having had intracerebral haemorrhage/periventricular leucomalacia development. Regression analysis demonstrated that only colloid infusion related significantly to abnormal neurodevelopmental outcome independent of other variables. CONCLUSION: These data suggest that colloid infusion should be used with caution in the perinatal period.

Rescue high frequency oscillation and predictors of adverse neurodevelopmental outcome in preterm infants.

BACKGROUND: High frequency oscillation (HFO) is now frequently used as rescue support, but it has been suggested that as many as one-third of survivors have abnormal neurodevelopmental findings at follow-up. OBJECTIVE: To identify risk factors for adverse neurodevelopmental outcome at 1 and 2 years in very prematurely born patients, who, because of severe neonatal respiratory failure, had required transfer to high frequency oscillation (HFO). METHODS: A case control study was performed. Controls were supported by conventional mechanical ventilation (CMV) only and matched to HFO infants for gestational age. At 1 and 2 years, neurodevelopmental status was assessed in both groups. Abnormal neurodevelopmental outcome was diagnosed if infants had impairment with or without disability or a Griffiths developmental quotient of at least two standard deviations below the mean. PATIENTS: Fifty-six infants were studied, median gestation age of 28 weeks (range 23--31). RESULTS: At 2 years of age, a greater proportion of the HFO infants compared to the controls had an abnormal outcome (p<0.05). HFO infants with an abnormal outcome compared to those with a normal outcome had poorer oxygenation prior to transfer to HFO (p=0.05), but did not have a lower initial improvement in oxygenation or longer duration of hypocarbia on HFO. Logistic regression demonstrated adverse outcomes significantly related to HFO use and gestational age in the whole study population and to gestational age in the HFO infants. CONCLUSION: An initial response to HFO does not guarantee normal neurodevelopmental outcome. Rescue HFO in very immature infants should be used cautiously.