Perioperative comprehensive geriatric assessment: what do we need to know?

As a consequence of an ageing population greater numbers of elderly patients are presenting for both elective and emergency surgery. These older patients typically present with an increased burden of age-related problems and multimorbidity, which is associated with an increased risk of adverse postoperative outcomes. Traditional preoperative assessment models are adept at discerning patients' suitability for anaesthesia and surgery, but there is minimal focus on improving postoperative outcomes. Comprehensive geriatric assessment is a multidisciplinary approach used both to assess existing 'known' pathology and to screen for previously undiagnosed issues across medical, functional, social and/or psychological domains. This diagnostic phase then leads to the development and implementation of an individualized 'optimization' strategy across these domains. There is emerging evidence that comprehensive geriatric assessment and optimization in the surgical setting leads to improved outcomes, and it is reasonable to conclude that it would benefit the patient's long-term health.

Perioperative Medicine for Older People.

Global demographic changes have resulted in an older, frailer surgical population with significant multimorbidity causing higher frequency of adverse postoperative outcomes. The need for restructuring of perioperative care pathways to address this issue has been recognised. Comprehensive geriatric assessment (CGA) and optimisation are emerging as innovative perioperative pathways. This paper describes one centre's approach in applying CGA in the surgical setting and presents the evidence in support of this. Similar models are being established in Singapore in hip fracture, colorectal and vascular populations. The challenges in the widespread adoption of such models of care are similar across settings. The global nature of translation is also discussed in this paper.

Successful Ageing in Singapore.

Singapore has experienced rapid development in the past 50 years. This has presented unique challenges with regard to land space and a rapidly ageing population. The role of extrinsic factors in successful ageing is well documented, and places a degree of responsibility on the state and healthcare systems. Singapore has taken many proactive measures to meet this responsibility by implementing policy changes across multiple domains including housing, transport, education and research. One hospital in the north east of Singapore has undertaken a frailty screening program that aims to identify, prevent and reverse frailty at an early stage. This paper provides a review of these national and regional measures.

High numbers of Staphylococcus aureus at three bathing beaches in South Florida.

While the value of Staphylococcus aureus as an indicator for non-enteric diseases is unclear, understanding its prevalence in recreational beaches would prove useful, given its pathogenic potential. Staphylococcus aureus levels were evaluated in sand and seawater at three beaches during one year. To elucidate possible S. aureus sources or colonization trends, distribution in sand was analyzed at Hollywood Beach. Staphylococcus aureus levels fluctuated throughout the study with highest average densities detected in dry sand (3.46 × 105 CFU/g, Hobie Beach), particularly at beaches with high human density. Patchy distribution marked hotspots of human use and/or possible bacterial re-growth. Data from a brief epidemiological survey indicated a very slight association between beach usage and skin conditions; suggesting high S. aureus levels in sand may not necessarily constitute major health risks. Because the possibility of disease transmission exists, particularly to children and immuno-compromised beach-goers, periodic surveying of highly frequented beaches seems warranted.

Complementary and alternative medicine use among women receiving chemotherapy for ovarian cancer in 2 patient populations.

OBJECTIVE: The authors evaluated attitudes toward complementary and alternative medicine (CAM) use in 2 populations of women receiving chemotherapy for epithelial ovarian cancer (EOC). METHODS: Women with EOC currently being treated with chemotherapy at 2 tertiary cancer centers, in Canada and the United Kingdom, completed a self-administered questionnaire on attitudes and perceptions of CAM and types of CAM used within the previous month. RESULTS: One hundred ninety-two patients (94 from Canada, 98 from United Kingdom) completed the questionnaire. Overall, 85 women (44%) were identified as CAM users. Complementary and alternative medicine use was more common among Canadian women (52%) compared with women from the United Kingdom (37%), P = 0.02. Participants used 71 different types of CAM, the majority (61%) taking multiple CAM. The frequency of CAM use was the same in primary compared with recurrent disease. Eighty-nine percent of CAM users considered it important for their oncologist to be aware of CAM use. Canadian women, however, were less likely to inform their physician (Canada: 50%; United Kingdom: 81%), P = 0.02. Motivations for CAM use were the same in both populations including assist healing (60%), boost the immune system (57%), improve quality of life (48%), and relieve symptoms (45%). Thirteen percent thought CAM could cure cancer, whereas 17% thought it would prevent recurrence. CONCLUSIONS: Complementary and alternative medicine use is common in women receiving chemotherapy for EOC. Increasingly, interactions between CAM and prescribed medication are being identified. Oncologists should be aware and actively inquire about CAM use. Although patterns of CAM use differed, the motivation for starting CAM was similar, highlighting the need to address supportive care in all patients.

First account of apochlorotic diatoms from mangrove waters in Florida.

From January to December 2004, monthly samples were collected from the mangrove salt marsh of J.U. Lloyd State Park, Florida, to examine the spatial and temporal distributions of heterotrophic diatoms in this subtropical region. Four non-pigmented (i.e. apochlorotic), heterotrophic diatom morphotypes were isolated from mangrove neuston and plankton sites. Colorless diatoms were numerically significant in neuston during the fall and winter months and counts peaked at 174 x 10³ cells/L in December. Heterotrophic diatoms were most prevalent in mangrove plankton in October and averaged 55.5 x 10³ cells/L. Valve morphology was detailed for mangrove morphotypes (I, II, V, and VI). However, only one type (I) was named with confidence (Nitzschia leucosigma). The other three types failed to conform closely to published diagnostic features suggesting that either characters are more variable than accepted or these types were new species. Growth responses to changes in salinity and irradiance were detailed in the laboratory. All morphotypes were euryhaline, tolerating salinities between 10% and 40%; N. leucosigma was most salt tolerant and grew from 10% to 60%. Maximum growth was achieved between 20% and 40%. Growth was not significantly different for heterotrophic diatoms during light and dark treatments or for diatoms grown with or without bacteria.

Prevalence and distribution of fecal indicator organisms in South Florida beach sand and preliminary assessment of health effects associated with beach sand exposure.

Fecal indicator levels in nearshore waters of South Florida are routinely monitored to assess microbial contamination at recreational beaches. However, samples of sand from the surf zone and upper beach are not monitored which is surprising since sand may accumulate and harbor fecal-derived organisms. This study examined the prevalence of fecal indicator organisms in tidally-affected beach sand and in upper beach sand and compared these counts to levels in the water. Since indicator organisms were statistically elevated in sand relative to water, the study also considered the potential health risks associated with beach use and exposure to sand. Fecal coliforms, Escherichia coli, enterococci, somatic coliphages, and F(+)-specific coliphages were enumerated from sand and water at three South Florida beaches (Ft. Lauderdale Beach, Hollywood Beach, and Hobie Beach) over a 2-year period. Bacteria were consistently more concentrated in 100g samples of beach sand (2-23 fold in wet sand and 30-460 fold in dry sand) compared to 100ml samples of water. Somatic coliphages were commonly recovered from both sand and water while F(+)-specific coliphages were less commonly detected. Seeding experiments revealed that a single specimen of gull feces significantly influenced enterococci levels in some 3.1m(2) of beach sand. Examination of beach sand on a micro-spatial scale demonstrated that the variation in enterococci density over short distances was considerable. Results of multiple linear regression analysis showed that the physical and chemical parameters monitored in this study could only minimally account for the variation observed in indicator densities. A pilot epidemiological study was conducted to examine whether the length of exposure to beach water and sand could be correlated with health risk. Logistic regression analysis results provided preliminary evidence that time spent in the wet sand and time spent in the water were associated with a dose-dependent increase in gastrointestinal illness.

Variable responses of Acanthamoeba strains to three multipurpose lens cleaning solutions.

PURPOSE: A novel method has been developed to compare Acanthamoeba strain differences by testing their susceptibility to multipurpose contact lens cleaning solutions (MPS). METHODS: This method uses surface-attached amoebae that mimic cells attached to a contact lens. In brief, acanthamoebae were grown on non-nutrient agar plates with Escherichia coli prey. Blocks of agar with cysts or trophozoites (approximately 50 cells) were cut out and transferred to MPS [ReNu MultiPlus; (Bausch & Lomb, Rochester, NY), Complete (Allergan, Irvine, CA), and Opti-Free Express (Alcon, Ft. Worth, TX)] for up to 24 h treatment. After neutralizing in Dey Engley broth (Difco), blocks were washed in amoeba saline and reinoculated onto fresh prey bacteria. Positive growth was indicative of survival. RESULTS: Testing showed that the efficacy of the three MPS was different. Opti-Free was the most effective against cysts, followed by ReNu while Complete was relatively ineffective. Not surprisingly, trophozoites were more susceptible than cysts. CONCLUSIONS: Findings for individual MPS complement previous work with other methods. This study has also identified that environmental strains vary in their sensitivity to disinfecting solutions. Overall, Acanthamoeba genotypes T3, T5, and T11 from the environment were more resistant than the T4 isolates from the cornea and beach. This resilience supports previous work on temperature tolerance, in which T3 and T5, and T11 acanthamoebae grew in temperatures up to 41 degrees C. Investigators should therefore consider the strain genotype and its source before embarking on MPS sensitivity testing.

Molecular and physiological evaluation of subtropical environmental isolates of Acanthamoeba spp., causal agent of Acanthamoeba keratitis.

Previous molecular examination of Acanthamoeba spp. has resulted in the determination of distinct genotypes in this genus (designated T1-T12, T14). Genotype T4 has been responsible for the majority of cases of Acanthamoeba keratitis. Here we examine the relative abundance of environmental T4 isolates on beaches and ask whether they have temperature and salinity tolerances that could enhance pathogenicity. Twenty-four Acanthamoeba strains were isolated from beach sand (n = 20), soil (n = 3), and tap water (n = 1) in south Florida. Phylogenetic analysis identified 19 of 24 isolates as T4, the Acanthamoeba keratitis-associated genotype. The remaining isolates were genotype T5 (4) and T11 (1). Nearly all beach isolates were genotype T4, whereas the tap water and soil isolates were mostly T5. All amoebae grew at 0, 1.0, and 2.0% salt and 19 of 20 beach isolates also grew at 3.2%. No soil or tap-water acanthamoebae reproduced at 3.2%. All isolates grew at 37 degrees C and two (T5) at 42 degrees C. Little correlation existed between beach location, salt-tolerance, and genetic relatedness. Overall, the large majority of environmental isolates obtained were genotype T4, suggesting it may be the most common genotype in this environment and could be a potential source of Acanthamoeba keratitis infections.

The application of peptide nucleic acid probes for rapid detection and enumeration of eubacteria, Staphylococcus aureus and Pseudomonas aeruginosa in recreational beaches of S. Florida.

A novel chemiluminescent in situ hybridization technique using peptide nucleic acids (PNA) was adapted for the detection of bacteria in beach sand and recreational waters in South Florida. The simultaneous detection and enumeration of eubacteria and the novel indicators, Staphylococcus aureus and Pseudomonas aeruginosa, was achieved within 6-8 h of processing. Following 5 h of incubation on TSA, soybean peroxidase-labeled peptide nucleic acid probes (Boston Probes, Boston, MA) targeting species-specific 16S rRNA sequences of P. aeruginosa and S. aureus were used to hybridize microcolonies of the target species in-situ. In addition, a universal probe for 16S rRNA sequences was used to target the eubacteria. Probes were detected after a light generating reaction with a chemiluminescent substrate and their presence recorded on Polaroid film. The probes showed limited cross-reactivity with mixed indigenous bacteria extracted from seawater and sand by shaking with phosphate-buffered saline (PBS). Specificity and cross-reactivity was tested on the reference bacterial genera Pseudomonas, Staphylococcus, Vibrio, Shigella, Salmonella, Acinetobacter, Enterobacter, Escherichia and Citrobacter. These tests confirmed that the probes were specific for the microorganisms of interest and were unaffected by high salt levels. The results of the PNA chemiluminescent in situ hybridization were compared with traditional plate count methods (PCM) for total 'freshwater' eubacteria, S. aureus and P. aeruginosa. Counts of eubacteria and S. aureus were comparable with numbers obtained from traditional plate counts but levels of P. aeruginosa were higher with PNA than with PCM. It is possible that PNA is more sensitive than PCM because it can detect microcolonies on the agar surface that never fully develop with the plate count method. We conclude that the in situ hybridization technique used here represents an important potential tool for the rapid monitoring of novel indicator organisms in beaches and recreational waters.

Identification and phylogenetic analysis of morphologically similar naked amoebae using small subunit ribosomal RNA.

Fan-shaped, naked amoebae are commonly encountered in samples from freshwater and marine habitats suggesting that they are an important component of the microbial food web. However, there are considerable problems in both detecting these amoebae and identifying them, given their morphological similarity. In this study we used restriction analysis and partial sequence analysis of the small-subunit 18S ribosomal RNA gene to examine the phylogenetic relationships between nine "fan-shaped" Vannella and Platyamoeba species. The molecular phylogeny showed that the marine Vannella and Platyamoeba isolates are closely related, whereas the freshwater isolates are disparate. Thus, the current reliance on the fine structure of the cell coat (glycocalyx) used to separate these genera is not justified. The study also highlights sequence elements that might be targeted by fluorescent probes for the direct detection of these amoebae in field samples. The molecular data were also used to aid the identification of three unknown fan-shaped isolates. All three unknowns resembled Vannella or Platyamoeba. However, one of the strains (a small < 10 microm, benthic, fan-shaped amoeba) probably represents a new genus.

Dry to wet weight biomass conversion constant for Tetrahymena elliotti (Ciliophora, Protozoa).

The wet and dry weights of both axenic and monoxenic cultures of the ciliate Tetrahymena were determined directly. These estimates are dependent upon the method of volume determination. Assuming a prolate spheroidal shape for the ciliate, we calculate a mean wet weight of 0.4157±0.0713 pg µm-3 and a mean dry weight of 0.2793±0.0652 pg µm-3. Using electronic cell sizing, our estimates are 0.7869±0.1659 pg µm-3 and 0.5239±0.1101 pg µm-3, respectively. Independent of the method of volume determination, we estimate a mean biomass conversion ratio (dry weight/wet weight) of 0.59±0.08.