Recovery of surgery in the elderly (ROSE) program: The efficacy of a multi-modal prehabilitation program implemented in frail and pre-frail elderly undergoing major abdominal surgery.

BACKGROUND: Major abdominal surgery is associated with a high rate of post-operative complications with increased risk of adverse surgical outcomes due to the presence of frailty. This study aims to evaluate the effectiveness of the multimodal Recovery of Surgery in the Elderly (ROSE) prehabilitation program with supervised exercise in mitigating postoperative functional decline when compared to standard care. METHOD: The ROSE program enrolled ambulant patients who were 65 years and above, had a Clinical Frailty Scale score of 4 or more and were planned for major abdominal surgery. Participation in supervised exercise sessions before surgery were compared with standard physiotherapy advice. The primary outcome was 6-min walk test (6MWT) distance assessed at baseline, after prehabilitation and 30 days follow-up after surgery. Secondary outcomes included physical performance, length of hospital stay and postoperative morbidity. RESULTS: Data from 74 eligible patients, 37 in each group, were included. Median age was 78 years old. Forty-two patients (22 in Prehab group and 20 in control group) with complete 6MWT follow-up data at 30 days follow-up were analysed for outcomes. Most patients underwent laparoscopic surgery (63.5%) and almost all of the surgeries were for abdominal malignancies (97.3%). The Prehab group had an increase in 6MWT distance at the 30-day follow up, from a baseline mean (SD) of 277.4 (125) m to 287.6 (143.5) m (p = 0.415). The 6MWT distance in the control group decreased from a baseline mean (SD) of 281.7 (100.5) m to 260.1 (78.6) m at the 30-day follow up (p = 0.086). After adjusting for baseline 6MWT distance and frailty score, the Prehab group had significantly higher 6MWT distance at 30-day follow-up than control (difference in adjusted means 41.7 m, 95% confidence interval 8.7-74.8 m, p = 0.015). There were no significant between-group differences in the secondary outcomes. CONCLUSION: A multimodal prehabilitation program with supervised exercise within a short time frame can improve preoperative functional capacity and maintain baseline functional capacity in frail older adults undergoing major abdominal surgery.

Preoperative Assessment of a Patient Undergoing Bariatric Surgery.

Over the past few decades, obesity rates in the United States have risen drastically, and with this, there has been a rising demand for bariatric surgery. As such, anesthesiologists need to be familiar with the challenges presented by patients seeking bariatric surgery. Obesity causes pathophysiologic changes which may affect decision-making during the management of these patients. Patients seeking bariatric surgery also have a long, prescribed preoperative course that offers anesthesiologists the opportunity to be involved earlier during the pre-surgical evaluation and optimization process.

Light-Controlled Switching of Perylene Bisimide Assemblies.

Light-driven changes in supramolecular interactions in perylene bisimides (PBIs) with pendant sulfur-containing functional groups at the bay position are demonstrated. In the ground state, a noncovalent S···X interaction between the σ-hole on sulfur and a heteroatom, X (X = O, N, S), of a neighboring molecule is the main driving force for intermolecular interactions, while in the excited state it is the π-π interaction between PBI scaffolds which drives assembly. The presence of heteroatoms in the solvent results in acceleration of the π-stacking process via the formation of a PBI-solvent complex. The excited-state dynamics involved in the assembly process were revealed via time-resolved fluorescence and transient absorption spectroscopies, while steady-state spectroscopy was used to evaluate the structure of the supramolecular assembly.

Effect of Oxidation on the Chiroptical Properties of Sulfur-Bridged Binaphthyl Dimers.

A series of axially chiral sulfur-bridged dimers were prepared from 1,1'-binaphthyl-2,2'-diol and subsequently oxidized to the respective sulfones. The chiroptical properties of the chiral chromophores were studied as a function of the oxidation state. Upon oxidation, an increase in quantum yields was observed for directly linked sulfur bridged binaphthyls (0.04 to 0.32), and a modest increase in dissymmetry factor was observed for diphenylsulfide-bridged binaphthyls (-8.9 × 10-4 to -1.4 × 10-3). Computational calculations were used to elucidate the changes in photophysical properties.

Control of photoluminescence quantum yield and long-lived triplet emission lifetime in organic alloys.

Two-component crystalline organic alloys with a wide range of compositional ratios (from 30% to 90% of one component) are employed to tune excited-state lifetimes and photoluminescence quantum yields (PLQYs). Alloy crystals exhibit homogeneous distribution of parent compounds by X-ray crystallography and differential scanning calorimetry. The alloys display a 1.5- to 5-fold enhancement in thermally activated delayed fluorescence (TADF) lifetime, compared to the parent compounds. PLQYs can also be tuned by changing alloy composition. The reverse intersystem crossing and long-lived lifetime of the parent compounds give rise to long-lived TADF in the alloys. Organic alloys enable tunability of both lifetime and efficiency, providing a new perspective on the development of organic long-lived emissive materials beyond the rules established for host-guest doped systems.

Sulfur-bridged chromophores for photofunctional materials: using sulfur oxidation state to tune electronic and structural properties.

The use of a heteroatom, such as sulfur, as a linker or bridge, in π-conjugated materials has advantages over purely carbon-based ones due to the accessibility of higher oxidation states as a result of hypervalence. Materials containing a sulfide bridge (S) can be systemically oxidized into sulfoxides (SO) and sulfones (SO2), each of which can then influence how a material interacts with light, playing a large role in dictating the photophysical and sometimes photochemical properties. In this perspective, we summarize the progress that our group and others have made, showing how oxidation of a sulfur bridge in symmetric bichromophoric dimers and in diimine ligands can influence the excited state behavior in organic π-conjugated materials and metal complexes.

Control over the Aspect Ratio of Supramolecular Nanosheets by Molecular Design.

Recent developments in kinetically controlled supramolecular polymerization permit control of the size (i.e., length and area) of self-assembled nanostructures. However, control of molecular self-assembly at a level comparable with organic synthetic chemistry and the achievement of structural complexity at a hierarchy larger than the molecular level remain challenging. This study focuses on controlling the aspect ratio of supramolecular nanosheets. A systematic understanding of the relationship between the monomer structure and the self-assembly energy landscape has derived a new monomer capable of forming supramolecular nanosheets. With this monomer in hand, the aspect ratio of a supramolecular nanosheet is demonstrated that it can be controlled by modulating intermolecular interactions in two dimensions.

Using sulfur bridge oxidation to control electronic coupling and photochemistry in covalent anthracene dimers.

Covalently tethered bichromophores provide an ideal proving ground to develop strategies for controlling excited state behavior in chromophore assemblies. In this work, optical spectroscopy and electronic structure theory are combined to demonstrate that the oxidation state of a sulfur linker between anthracene chromophores gives control over not only the photophysics but also the photochemistry of the molecules. Altering the oxidation state of the sulfur linker does not change the geometry between chromophores, allowing electronic effects between chromophores to be isolated. Previously, we showed that excitonic states in sulfur-bridged terthiophene dimers were modulated by electronic screening of the sulfur lone pairs, but that the sulfur orbitals were not directly involved in these states. In the bridged anthracene dimers that are the subject of the current paper, the atomic orbitals of the unoxidized S linker can actively mix with the anthracene molecular orbitals to form new electronic states with enhanced charge transfer character, different excitonic coupling, and rapid (sub-nanosecond) intersystem crossing that depends on solvent polarity. However, the fully oxidized SO2 bridge restores purely through-space electronic coupling between anthracene chromophores and inhibits intersystem crossing. Photoexcitation leads to either internal conversion on a sub-20 picosecond timescale, or to the creation of a long-lived emissive state that is the likely precursor of the intramolecular [4 + 4] photodimerization. These results illustrate how chemical modification of a single atom in the covalent bridge can dramatically alter not only the photophysics but also the photochemistry of molecules.

Dynamic anti-counterfeiting security features using multicolor dianthryl sulfoxides.

A new concept for difficult-to-replicate security inks for use in advanced anti-counterfeiting applications is presented. Inks fabricated from a mixture of photoactive dyes result in a unique fluorescent color upon irradiation that differs from the starting fluorescence. The dyes are substituted 9,9'-dianthryl sulfoxides that undergo photochemical extrusion of a sulfoxide moiety (SO) to produce emissive red, blue, and green emitters. The resulting emissive feature has specific Commission international de l'éclairage (CIE) coordinates that are used for authentication. Additionally, the temporal evolution of the fluorescence can be monitored, introducing a dynamic nature to these security features. The three compounds show different rates of photoconversion dependent on the irradiation wavelength, allowing selective wavelengths for activation to be used for additional security. CIE coordinates can be extracted from patches containing the three compounds using an inexpensive, commercially available smartphone application (app) and compared against a known value to confirm the validity of the method.

Interactions of Subjective and Objective Measures of Fatigue Defined in the Context of Brain Control of Locomotion.

Background: Fatigue adversely impacts quality of life in old age. The relationship between subjective and objective measurements of fatigue, however, is poorly understood. We examined whether subjective fatigue moderated the expression of objective fatigue during locomotion. Associations between objective and subjective measures of fatigue were predicted to manifest only under dual-task conditions that maximized cognitive demands. Methods: Participants were 314 nondemented older adults (age = 76.8±6.7 years; % female = 56). Functional near-infrared spectroscopy was used to assess oxygenated hemoglobin (HbO2) levels during walking. A 4×14-foot Zeno electronic walkway was utilized to assess stride velocity (cm/s). Objective fatigue was operationalized as attenuation in HbO2 levels and decline in stride velocity (cm/s) during six continuous straight walks under single- (normal-walk) and dual-task (walk-while-talk) conditions. The Brief Fatigue Inventory assessed subjective fatigue. Results: Worse subjective fatigue was associated with attenuated increase in HbO2 levels (estimate = 0.175; p < .05) but not with decline in stride velocity (estimate = 0.394; p > .05) from normal-walk to walk-while-talk conditions. Objective fatigue did not manifest and was not associated with subjective fatigue during the course of normal-walk. Worse subjective fatigue was associated with attenuated HbO2 levels in the fourth (estimate = -0.178; p < .05), fifth (estimate = -0.230; p < .01), and sixth (estimate = -0.231; p < .01) straight walks compared to the first during walk-while-talk. Conclusion: Dual-task walking paradigms provide a unique environment to simultaneously assess different facets of fatigue. The prefrontal cortex subserves both subjective and objective measurements of fatigue as defined in the context of attention-demanding locomotion.

White Matter Hyperintensities in Older Adults and Motoric Cognitive Risk Syndrome.

INTRODUCTION: Motoric cognitive risk (MCR) syndrome is a recently described pre-dementia syndrome characterized by slow gait and cognitive complaints that has been implicated as a predictor of cognitive decline and dementia in older adults. Previous work suggests that cerebrovascular disease is associated with MCR. White matter hyperintensities (WMH) are postulated to be a product of cerebrovascular disease, and have been associated with impaired mobility and impaired cognition. This study aimed to determine if MCR is associated with regional WMH. METHODS: Two cross-cultural cohorts of non-demented older adults were examined: 174 from a French memory clinic (62.1% male, mean age 70.7 ± 4.3 years) and 184 from an Indian community-dwelling cohort (55.4% male, mean age 66.2 ± 5.2 years). Participants were evaluated for slow gait, cognitive complaints, and regional WMH via MRI (fluid attenuated inversion recovery) FLAIR sequence. RESULTS: Overall, 20.7% of participants met criteria for MCR, and 72.9% of participants had WMH on FLAIR. WMH in the frontal, parieto-occipital, temporal, basal ganglia, cerebellum, or brainstem were not associated with MCR in either of the two cohorts. CONCLUSION: WMH was not significantly associated with MCR in this studied sample of participants, suggesting that other cerebrovascular pathophysiological mechanisms, or combination of mechanisms, might underlie MCR.

Functional connectivity associated with gait velocity during walking and walking-while-talking in aging: a resting-state fMRI study.

Gait decline is common among older adults and is a risk factor for adverse outcomes. Poor gait performance in dual-task conditions, such as walking while performing a secondary cognitive interference task, is associated with increased risk of frailty, disability, and death. Yet, the functional neural substrates that support locomotion are not well established. We examined the functional connectivity associated with gait velocity in single- (normal pace walking) and dual-task (walking while talking) conditions using resting-state functional Magnetic Resonance Imaging (fMRI). We acquired 6 minutes of resting-state fMRI data in 30 cognitively healthy older adults. Independent components analyses were performed to separate resting-state fMRI data into group-level statistically independent spatial components that correlated with gait velocity in single- and dual-task conditions. Gait velocity in both task conditions was associated with similar functional connectivity in sensorimotor, visual, vestibular, and left fronto-parietal cortical areas. Compared to gait velocity in the single-task condition, the networks associated with gait velocity in the dual-task condition were associated with greater functional connectivity in supplementary motor and prefrontal regions. Our findings show that there are partially overlapping functional networks associated with single- and dual-task walking conditions. These initial findings encourage the future use of resting-state fMRI as tool in developing a comprehensive understanding of age-related mobility impairments.

Hospitalizations in children with preexisting tracheostomy: a national perspective.

OBJECTIVES/HYPOTHESIS: To describe the reasons for hospitalization and characteristics of children with preexisting tracheostomy and to compare hospital utilization between children with and without tracheostomy. STUDY DESIGN: Retrospective cohort study. METHODS: Children with tracheostomy were selected in the Healthcare Cost and Utilization Project Kids' Inpatient Database 2009 using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We compared hospital utilization with the children's clinical characteristics (e.g., chronic condition number and type). We also assessed hospitalizations for tracheostomy complications and ambulatory care sensitive conditions (ACSCs) that could be potentially influenced by high-quality outpatient and community care delivery. RESULTS: In 2009, there were 21,541 hospitalizations for children with tracheostomy totalling $1.4 billion (U.S.). On average, children with tracheostomy had five chronic conditions (standard deviation 1.4). Eighty-one percent (n = 17,448) had one or more complex chronic conditions (CCCs), and 67.1% (n = 14,379) had a gastrostomy. Among children with one or more CCCs, mean hospital charges were greater for hospitalizations of children with tracheostomy compared to without ($69,999 vs. $64,017, P = 0.008). Twenty-one percent (n = 4,421) of all hospitalizations of children with tracheostomy were due to an ACSC (14.5%, n = 3,122) or a tracheostomy complication (6.0%, n = 1,299). Bacterial pneumonia (9.6% of all hospitalizations, n = 2,059) was the most common ACSC. CONCLUSIONS: Children with tracheostomy are a vulnerable group of children with multiple CCCs who experience lengthy and costly hospitalizations. Many hospitalizations are due to an ambulatory care sensitive condition or a tracheostomy complication. Further investigation is needed to determine whether some of these hospitalizations may be avoidable with improved outpatient and community tracheostomy care. LEVEL OF EVIDENCE: 2b.

Indications, Hospital Course, and Complexity of Patients Undergoing Tracheostomy at a Tertiary Care Pediatric Hospital.

OBJECTIVE: The purpose of this study was to review inpatients undergoing tracheostomies at a tertiary care pediatric hospital in a 24-month period and to identify the indications, comorbidities, hospital course, patient complexity, and predischarge planning for tracheostomy care. The goal was to analyze these factors to highlight potential areas for improvement. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care pediatric hospital. SUBJECTS: Ninety-five inpatients at Boston Children's Hospital requiring a primary or revision tracheostomy during the 24-month period encompassing 2010 to 2011. METHODS: Inpatients undergoing tracheostomy during the study period were identified using 2 different databases: the Boston Children's Hospital Department of Otolaryngology and Communication Enhancement database and institution-specific information from the Child Health Corporation of America's Pediatric Health Information System (PHIS). We extracted the specified metrics from the inpatient charts. RESULTS: Patients undergoing tracheostomy are complex, with an average of 3.4 comorbidities and 13.6 services involved in their care. The tracheostomy was mentioned in 97.9% of physician and 69.5% of nurse discharge notes, and 42.5% of physician discharge notes contained a plan or appointment for follow-up. Of the patients, 33.7% were discharged home (27.3% of the nonanatomic group and 52.4% of the anatomic group). Overall, 8.4% of tracheostomy patients died before discharge. CONCLUSION: The complexity of pediatric tracheostomy patients presents challenges and opportunities for optimizing quality of care for these children. Future directions include the introduction and assessment of multidisciplinary tracheostomy care teams, tracheostomy nurse specialists, and tracheostomy care plans in the pediatric setting.

Optimal duration of cooling for an acute scald contact burn injury in a porcine model.

The Australian and New Zealand Burn Association recommend 20 minutes of cold running tap water as burn first aid. Scientific evidence for the optimal duration of treatment is limited. Our aim was to establish the optimal duration of cooling using cold running tap water to treat the acute burn. Partial thickness contact scald burns were induced at five sites in each of 17 pigs. Treatments with cold running tap water for 5, 10, 20, and 30 minutes were randomly allocated to different sites together with an untreated control site. In the running water 5 and 10 minute treatments intradermal temperatures rose by 1 degrees C per minute when cooling was stopped, compared with 0.5 degrees C per minute for 20 and 30 minutes duration. No differences in the surface area of each burn were noted between the five treatments on day 9. Histological analysis of burn depth on days 1 and 9 revealed that a higher proportion of burns treated for 20 and 30 minutes showed improvement compared with those treated for 5 and 10 minutes only. This difference reached statistical significance (P < .05) only in the cold running water for 20 minutes treatment arm. There was a statistically significant (P < .05) improvement in burn depth in a porcine acute scald burn injury model when the burn was treated with cold running tap water for 20 minutes as opposed to the other treatment durations. This study supports the current burn first aid treatment recommendations for the optimal duration of cooling an acute scald burn.

Assessment of cooling on an acute scald burn injury in a porcine model.

The current Australian and New Zealand Burn Association (ANZBA) recommended Burns First Aid Treatment is place the burn under cool running water for 20 minutes. Wet towels and water spray also have been used frequently. No scientific data exist to compare the effectiveness of these methods of cooling. This study sought to determine experimental evidence for current Burns First Aid Treatment recommendations and the optimal mode of cooling. Four partial-thickness scald burn injuries were induced in 10 piglets each. First aid was then applied for 20 minutes via cool running water, wet towels, or water spray, with no treatment as a control. At day 1 and day 9, biopsies and clinical photographs were assessed in a blinded manner. The control group showed worsening or no change of depth over the course of 9 days. The outcomes with wet towels and water spray were variable. Cool running water consistently demonstrated improvement in wound recovery over the course of 9 days (P < .05). This study demonstrated that cool running water appeared the most effective first aid for an acute scald burn wound in a porcine model compared with wet towels and water spray.