Multicomponent perioperative interventions to improve outcomes for frail patients: a systematic review.

BACKGROUND: Preoperative frailty is associated with increased risk of adverse outcomes. In 2017, McIsaac and colleagues' systematic review found that few interventions improved outcomes in this population and evidence was low-quality. We aimed to systematically review the evidence for multicomponent perioperative interventions in frail patients that has emerged since McIsaac et al.'s review. METHODS: PUBMED, EMBASE, Cochrane, and CINAHL databases were searched for English-language studies published since January 1, 2016, that evaluated multicomponent perioperative interventions in patients identified as frail. Quality was assessed using the National Institute of Health Quality Assessment Tool. A narrative synthesis of the extracted data was conducted. RESULTS: Of 2835 articles screened, five studies were included, all of which were conducted in elective oncologic gastrointestinal surgical populations. Four hundred and thirteen patients were included across the five studies and the mean/median age ranged from 70.1 to 87.0 years. Multicomponent interventions were all applied in the preoperative period. Two studies also applied interventions postoperatively. All interventions addressed exercise and nutritional domains with variability in timing, delivery, and adherence. Multicomponent interventions were associated with reduced postoperative complications, functional deterioration, length of stay, and mortality. Four studies reported on patient-centred outcomes. The quality of evidence was fair. CONCLUSIONS: This systematic review provides evidence that frail surgical patients undergoing elective oncologic gastrointestinal surgery may benefit from targeted multicomponent perioperative interventions. Yet methodological issues and substantial heterogeneity of the interventions precludes drawing clear conclusions regarding the optimal model of care. Larger, low risk of bias studies are needed to evaluate optimal intervention delivery, effectiveness in other populations, implementation in health care settings and ascertain outcomes of importance for frail patients and their carers.

"Doing well": Intraoperative entrustable professional activity assessments provided limited technical feedback.

Background: Entrustable Professional Activities (EPAs) allow for the assessment of specific, observable, essential tasks in medical education. Since being developed in non-surgical fields, EPA assessments have been implemented in surgery to explore intraoperative entrustment. However, assessment burden is a significant problem for faculty, and it is unknown whether EPA assessments enable formative technical feedback. EPAs' formative utility could inform how surgical programs facilitate technical feedback for trainees. We aimed to assess the extent to which narrative comments provided through the Fellowship Council (FC) EPA assessments contained technical feedback. Methods: The FC previously collected EPA assessments for subspecialty surgical fellows from September 2020 to October 2022. Two raters reviewed assessments' narrative comments for inclusion of each skill area that makes up part of the Objective Structured Assessment of Technical Skills (OSATS). A third rater reconciled discrepant ratings. Results: During the study period, there were 3302 completed EPA assessments, including 1191 fellow self-assessments, 1124 faculty assessments, and 987 assessments without an identified assessor role. We found that assessments' narrative comments related to a median of two of the seven OSATS areas (IQR:1-2). There were no comments relevant to any of the seven OSATS areas in 16.0 % of all assessments. Conclusions: In this review of narrative comments for EPA assessments from the FC, we found that limited technical feedback of the kind included in the OSATS was provided in many assessments. These results suggest benefit to adjusting the EPA form, enhancing faculty development, or continuing additional types of targeted technical assessment intraoperatively. Key message: This analysis of narrative comments from fellowship EPA assessments showed that many assessments included limited technical feedback. To allow for continued technical feedback for fellows, these results highlight the need for further refinements of the EPA assessment form, additional faculty development, or ongoing use of other types of technical assessment.

Improving post-acute stroke follow-up care by adopting telecare consultations in a nurse-led clinic: Study protocol of a hybrid implementation-effectiveness trial.

AIM: To evaluate the clinical effectiveness and implementation strategies of telecare consultations in post-stroke nurse-led clinics. BACKGROUND: Telecare consultations could be an alternative to conventional in-person consultations and improve continuity of care for stroke survivors following their discharge from hospital. Previous studies utilizing telecare consultations only focused on testing their clinical effectiveness on stroke survivors; the appropriateness and feasibility of adopting this new delivery modality in a real-world setting were not examined. DESIGN: A Type II hybrid effectiveness-implementation design will be adopted. METHODS: Eligible stroke survivor participants will be randomly assigned to the intervention group (telecare consultation) or control group (usual in-person clinic consultation). Both groups will receive the same nursing intervention but delivered through different channels. The Reach, Effectiveness, Adoption, Implementation, Maintenance framework will be used to evaluate the clinical effectiveness and implementation outcomes. The primary outcome is the non-inferiority of the degree of disability between the two groups at 3 months into the intervention and at 3 months post-intervention. The paper complies with the SPIRIT guidelines for study protocols adapted for designing and reporting parallel group randomized trials. CONCLUSION: The findings of this study will provide key insights into the processes for implementing and adopting telecare consultations into long-term services for post-stroke patients. IMPACT: This study contributes to the translation of telecare consultations for stroke survivors into real-life settings. If effective, this program may provide guidance for expanding telecare consultations to other post-stroke nurse-led clinics or to patients with other chronic diseases. TRIAL REGISTRATION: This study has been registered at clinicaltrials.gov (identifier: NCT05183672). Registered on 10 January 2022.

The feasibility and effectiveness of telecare consultations in nurse-led post-acute stroke clinics: A study protocol.

Background: Globally, nurse-led post-acute stroke clinics have been developed to provide secondary care services to stroke survivors. Although synthesized evidence supports the idea that the secondary prevention services delivered by nurses in these clinics can improve the functional ability of stroke survivors and reduce their readmission rates, long travel and waiting times, high costs, and the pandemic have limited the utilization of such clinics. Telecare consultations are a new modality for expanding public access to healthcare services, although how it can be applied in nurse-led clinics has not been reported. Objective: The aim of this study is to determine the feasibility and effects of telecare consultations in nurse-led post-acute stroke clinics. Methods: The study adopts a quasi-experimental design. The participants will receive three secondary stroke care consultations in 3 months provided via telecare by experienced advanced practice nurses. The outcome measures include feasibility (reasons for refusing to participate and for dropping-out, the attitudes and satisfaction of both the advanced practice nurses and their patients towards the programme), and preliminary effectiveness (degree of disability after stroke, activities of daily living, instrumental activities of daily living, health-related quality of life, depression) outcomes. Data will be collected at pre-(T1) and post-(T2) intervention. Conclusions: The findings of this study may help facilitate the implementation of telecare consultations in a nurse-led post-acute stroke clinic, which may benefit the stroke survivors who are having mobility restrictions from accessing customary healthcare services and may protect them from being exposed to the infectious risk.

Sustaining telecare consultations in nurse-led clinics: Perceptions of stroke patients and advanced practice nurses: A qualitative study.

Objective: The ongoing pandemic has accentuated the use of telecare services; however, only limited progress has been made in understanding the barriers and facilitators to using these services. In order to move towards sustaining such essential services, the present study aimed to ascertain the experiences of stroke survivors and healthcare providers regarding the utilization of a post-stroke telecare service in Hong Kong. Methods: Interpretive description was employed for this study. Semi-structured discussions and interviews were undertaken with nine stroke survivors and four stroke nurses who delivered the telecare services. The principles of thematic analysis were inductively followed to analyse the data. The Standards for Reporting Qualitative Research checklist was used to guide the reporting of the data. Results: Three themes emerged: (a) pre-existing post-discharge service pathways; (b) push factors/facilitators for telecare usage; and (c) barriers to telecare usage. Overall, the telecare service was considered a significant alternative and one that complements conventional face-to-face follow-ups. Stroke survivors were motivated to use the service because it was convenient and flexible. However, significant barriers exist, including technical issues and a lack of guidelines and training opportunities for healthcare providers. Conclusions: Although telecare is still evolving, several factors drive stroke survivors to use the service. Attention needs to be paid to the emerging barriers to improve long-term usage of the service. Clear guidelines are needed to underpin the development and implementation of telecare services.

Prevalence and predictors of medication non-adherence among Chinese patients with first-episode psychosis.

Medication non-adherence is one of the major obstacles to recovery in first-episode psychosis (FEP). This study aimed to identify the predictors and rates of medication non-adherence in the first and second year after the start of treatment (baseline) in urban Chinese FEP patients. Relevant information on medication non-adherence and potential baseline predictors, including demographic variables, clinical measures, violence/suicide attempts, stressful life experiences, intervention received, and follow-up attendance, were collected from case records of 1400 FEP patients in Hong Kong. The non-adherence rate was 16.2% in year 1 and 15.4% in year 2. Regression analyses revealed the predictors for non-adherence in year 1 were no hospitalization at baseline, non-schizophrenia diagnosis, and more years of education. Predictors of non-adherence in year 2 included acute/subacute onset and older age of onset. Predictors common in both years were defaulting from psychiatric follow-up during baseline, standard psychiatric care (no early intervention), and lower positive symptoms severity at baseline. In assessing non-adherence risk and for planning phase-specific early interventions for FEP, particularly in a Chinese context, healthcare professionals should consider the common and specific predictors for non-adherence identified in the first and second years of treatment and should not overlook patients with less clinically severe symptoms.

Telephone and Teleradiology-Guided Thrombolysis Can Achieve Similar Outcome as Thrombolysis by Neurologist On-site.

BACKGROUND: Because of the limitation of on-site neurology workforce, telestroke was implemented to overcome this barrier. We explored the efficacy and safety of intravenous (IV) stroke thrombolysis service by telestroke when neurologist was not available on-site. METHODS: From January 2009 to December 2012, we compared patients treated with IV stroke thrombolysis by telestroke in the form of telephone consultation with teleradiology, to patients treated after in-person assessment by the same team of neurologists in a regional hospital. Door-to-needle time, symptomatic intracranial hemorrhage, and functional outcome at 3 months were prospectively collected and compared between the groups. RESULTS: In all, 152 patients were treated with IV thrombolysis; 102 patients were treated with neurologist on-site; whereas 50 patients were treated by internists with telestroke. Fifty-two percent of the telemedical group achieved excellent outcome compared to 43% of the neurologist on-site group (P = .30). Symptomatic intracranial hemorrhage rate (4.0% versus 4.9%, P = 1.0) and mortality (8.3% versus 11.9%, P = .49) were comparable. Using the multiple logistic regression analysis, age, baseline stroke severity, and extent of early ischemic change on brain computed tomography scan, are independent predictors for excellent outcome, whereas the presence of neurologist on-site is not correlated with the outcome. CONCLUSIONS: Patients treated without neurologist on-site achieved similar outcome. Telephone consultation and teleradiology-guided IV stroke thrombolysis, with the support of on-site internist appeared safe and efficacious.

Use of fluorescent probes to detect lipid signaling intermediates in macrophages.

To fulfill their function in host defense, professional phagocytes such as neutrophils and macrophages exhibit the ability to ingest (phagocytose), kill, and dispose of pathogenic microorganisms. Recent studies have provided strong evidence for the importance of membrane lipids such as polyphosphoinositides in these processes. In turn, reversible phosphorylation events, involving protein and lipid kinases and phosphatases, regulate signaling pathways involving metabolism of membrane lipids. Our ability to study lipid signaling events has been greatly facilitated by the development of fluorescent molecular imaging techniques. In particular, the expression of recombinant fusions of derivatives of the jellyfish-derived green fluorescent proteins (GFP) coupled to reporter molecules enables real-time monitoring of signaling events in live cells. Here, we discuss methods to monitor alterations in membrane polyphosphoinositides involved in signaling events regulating phagocytosis. To illustrate the use of this technology, we will focus on the role of protein tyrosine phosphatase MEG2 in phagocytosis and its modulation by phosphatidylinositol-3,4,5-triphosphate (PIP3). This approach enables investigators to ascertain the involvement of lipid intermediates in diverse signaling pathways.

Tyrosine phosphatase PTPalpha regulates focal adhesion remodeling through Rac1 activation.

We characterized the role of protein tyrosine phosphatase (PTP)-alpha in focal adhesion (FA) formation and remodeling using wild-type and PTPalpha-deficient (PTPalpha(-/-)) cells. Compared with wild-type cells, spreading PTPalpha(-/-) fibroblasts displayed fewer leading edges and formed elongated alpha-actinin-enriched FA at the cell periphery. These features suggest the presence of slowly remodeling cell adhesions and were phenocopied in human fibroblasts in which PTPalpha was knocked down using short interfering RNA (siRNA) or in NIH-3T3 fibroblasts expressing catalytically inactive (C433S/C723S) PTPalpha. Fluorescence recovery after photobleaching showed slower green fluorescence protein-alpha-actinin recovery in the FA of PTPalpha(-/-) than wild-type cells. These alterations correlated with reduced cell spreading, adhesion, and polarization and retarded contraction of extracellular matrices in PTPalpha(-/-) fibroblasts. Activation of Rac1 and its recruitment to FA during spreading were diminished in cells expressing C433S/C723S PTPalpha. Rac1(-/-) cells also displayed abnormally elongated and peripherally distributed FA that failed to remodel. Conversely, expression of constitutively active Rac1 restored normal FA remodeling in PTPalpha(-/-) cells. We conclude that PTPalpha is required for remodeling of FA during cell spreading via a pathway involving Rac1.

CD44-mediated phagocytosis induces inside-out activation of complement receptor-3 in murine macrophages.

Diverse receptors, including Fcgamma receptors and beta(2) integrins (complement receptor-3 [CR3], CD11b/CD18), have been implicated in phagocytosis, but their distinct roles and interactions with other receptors in particle engulfment are not well defined. CD44, a transmembrane adhesion molecule involved in binding and metabolism of hyaluronan, may have additional functions in regulation of inflammation and phagocytosis. We have recently reported that CD44 is a fully competent phagocytic receptor that is able to trigger ingestion of large particles by macrophages. Here, we investigated the role of coreceptors and intracellular signaling pathways in modulation of CD44-mediated phagocytosis. Using biotinylated erythrocytes coated with specific antibodies (anti-CD44-coated erythrocytes [Ebabs]) as the phagocytic prey, we determined that CD44-mediated phagocytosis is reduced by 45% by a blocking CD11b antibody. Further, CD44-mediated phagocytosis was substantially (42%) reduced in CD18-null mice. Immunofluorescence microscopy revealed that CD11b is recruited to the phagocytic cup. The mechanism of integrin activation and mobilization involved activation of the GTPase Rap1. CD44-mediated phagocytosis was also sensitive to the extracellular concentration of the divalent cation Mg(2+) but not Ca(2+). In addition, buffering of intracellular Ca(2+) did not affect CD44-mediated phagocytosis. Taken together, these data suggest that CD44 stimulation induces inside-out activation of CR3 through the GTPase Rap1.

CD44 is a phagocytic receptor.

CD44, a transmembrane adhesion molecule involved in binding and metabolism of hyaluronan, has additional functions in inflammatory and immune responses, contributing to the ingestion and clearance of particles and apoptotic cells. Our goal was to determine the specific role of CD44 in phagocytosis and whether it functions as a primary or accessory phagocytic receptor. Using hyaluronan-coated beads and erythrocytes coated with antiCD44 antibodies as the phagocytic prey, we determined that CD44 mediates efficient phagocytosis in primary murine peritoneal macrophages and in the murine macrophage cell line RAW 264.7. In RAW cells, the phagocytic index for anti-CD44-coated erythrocytes was 25 +/- 3 (mean +/- SEM) compared with less than 1 for erythrocytes coated with isotype-matched control antibodies. Uptake of anti-CD44-coated erythrocytes was abrogated by pretreatment with a blocking antibody to CD44 and was absent in primary cultures of CD44-deficient murine macrophages. Down-regulation of Fc receptors by aggregated IgG-induced internalization, which blocks uptake of IgG-coated particles, had no effect on CD44-mediated particle engulfment. Using a combination of immunoprecipitation, pharmacologic inhibition, and genetic deletion, we determined that CD44-mediated phagocytosis involves Syk, Rac1, and phosphatidylinositol 3-kinase and induced activation of the phagocyte oxidase. We conclude that CD44 is a competent phagocytic receptor that efficiently mediates internalization of large particles.