Frailty and post-operative outcomes in older surgical patients: a systematic review.

BACKGROUND: As the population ages, increasing numbers of older adults are undergoing surgery. Frailty is prevalent in older adults and may be a better predictor of post-operative morbidity and mortality than chronological age. The aim of this review was to examine the impact of frailty on adverse outcomes in the 'older old' and 'oldest old' surgical patients. METHODS: A systematic review was undertaken. Electronic databases from 2010 to 2015 were searched to identify articles which evaluated the relationship between frailty and post-operative outcomes in surgical populations with a mean age of 75 and older. Articles were excluded if they were in non-English languages or if frailty was measured using a single marker only. Demographic data, type of surgery performed, frailty measure and impact of frailty on adverse outcomes were extracted from the selected studies. Quality of the studies and risk of bias was assessed by the Epidemiological Appraisal Instrument. RESULTS: Twenty-three studies were selected for the review and they were assessed as medium to high quality. The mean age ranged from 75 to 87 years, and included patients undergoing cardiac, oncological, general, vascular and hip fracture surgeries. There were 21 different instruments used to measure frailty. Regardless of how frailty was measured, the strongest evidence in terms of numbers of studies, consistency of results and study quality was for associations between frailty and increased mortality at 30 days, 90 days and one year follow-up, post-operative complications and length of stay. A small number of studies reported on discharge to institutional care, functional decline and lower quality of life after surgery, and also found a significant association with frailty. CONCLUSION: There was strong evidence that frailty in older-old and oldest-old surgical patients predicts post-operative mortality, complications, and prolonged length of stay. Frailty assessment may be a valuable tool in peri-operative assessment. It is possible that different frailty tools are best suited for different acuity and type of surgical patients. The association between frailty and return to pre-morbid function, discharge destination, and quality of life after surgery warrants further research.

The prognostic validity of delirium severity as measured by Delirium Observation Screening Scale (DOS scale) on adverse outcomes.

OBJECTIVE: To investigate whether an assessment of delirium severity at diagnosis using the Delirium Observation Screening Scale (DOS scale) predicts adverse outcomes in hospital and on discharge. METHODS: A prospective cohort study was conducted on a convenience sample of patients admitted to an acute geriatric ward with delirium over an eight-month period. DOS scale was administered to the patients within 48 h of delirium diagnosis to measure delirium severity. Univariate logistic regression analysis was performed to evaluate the correlation between DOS scale and adverse outcomes. RESULTS: Fifty-nine patients were included in the study. There was a moderate correlation between increasing DOS scores and duration of delirium (r = 0.46, p < 0.001), as well as increasing DOS scores and decline in mobility on discharge (r = 0.35, p = 0.007). There was a weak correlation between increasing DOS scores and functional decline as measured by change in Katz Index from admission to discharge (r = -0.27, p = 0.04). No statistically significant correlations were found between DOS scores and in-hospital mortality, inpatient complication rates or discharge to higher level of care. CONCLUSION: Delirium severity as measured by DOS scale may be useful in predicting delirium duration and decline in mobility and function on discharge. Further research with larger sample sizes is needed to establish if this finding can be replicated and whether delirium severity predicts additional adverse outcomes. Measuring delirium severity at diagnosis may be useful for communicating prognostic information to family members and setting expectations and treatment goals.

SNS alleviates depression-like behaviors in CUMS mice by regluating dendritic spines via NCOA4-mediated ferritinophagy.

ETHNOPHARMACOLOGICAL RELEVANCE: Depression is one of the most common mood disturbances worldwide. The Si-ni-san formula (SNS) is a famous classic Traditional Chinese Medicine (TCM) widely used to treat depression for thousands of years in clinics. However, the mechanism underlying the therapeutic effect of SNS in improving depression-like behaviors following chronic unpredictable mild stress (CUMS) remains unknown. AIM OF THE STUDY: This study aimed to investigate whether SNS alleviates depression-like behaviors in CUMS mice by regulating dendritic spines via NCOA4-mediated ferritinophagy in vitro and in vivo. STUDY DESIGN AND METHODS: In vivo, mice were exposed to CUMS for 42 days, and SNS (4.9, 9.8, 19.6 g/kg/d), fluoxetine (10 mg/kg/d), 3-methyladenine (3-MA) (30 mg/kg/d), rapamycin(1 mg/kg/d), and deferoxamine (DFO) (200 mg/kg/d) were conducted once daily during the last 3 weeks of the CUMS procedure. In vitro, a depressive model was established by culture of SH-SY5Y cells with corticosterone, followed by treatment with different concentrations of freeze-dried SNS (0.001, 0.01, 0.1 mg/mL) and rapamycin (10 nM), NCOA4-overexpression, Si-NCOA4. After the behavioral test (open-field test (OFT), sucrose preference test (SPT), forced swimming test (FST) and tail suspension test (TST), dendritic spines, GluR2 protein expression, iron concentration, and ferritinophagy-related protein levels (P62, FTH, NCOA4, LC3-II/LC3-I) were tested in vitro and in vivo using immunohistochemistry, golgi staining, immunofluorescence, and Western blot assays. Finally, HEK-293T cells were transfected by si-NCOA4 or GluR2-and NCOA4-overexpression plasmid and treated with corticosterone(100 µM), freeze-dried SNS(0.01 mg/mL), rapamycin(25 nM), and 3-MA(5 mM). The binding amount of GluR2, NCOA4, and LC3 was assessed by the co-immunoprecipitation (CO-IP) assay. RESULTS: 3-MA, SNS, and DFO promoted depressive-like behaviors in CUMS mice during OFT, SPT, FST and TST, improved the amount of the total, thin, mushroom spine density and enhanced GluR2 protein expression in the hippocampus. Meanwhile, treatment with SNS decreased iron concentrations and inhibited NCOA4-mediated ferritinophagy activation in vitro and in vivo. Importantly, 3-MA and SNS could prevent the binding of GluR2, NCOA4 and LC3 in corticosterone-treated HEK-293T, and rapamycin reversed this phenomenon after treatment with SNS. CONCLUSION: SNS alleviates depression-like behaviors in CUMS mice by regulating dendritic spines via NCOA4-mediated ferritinophagy.

Electrosynthesis of (hetero)aryl nitriles from α-imino-oxy acids via oxidative decarboxylation/N-O cleavage.

A new method for the synthesis of (hetero)aryl nitriles via iminyl radicals has been developed through the electrochemical oxidative decarboxylation of α-imino-oxy acids. This protocol provides an efficient approach to nitriles with a broad range of functional-group tolerance under ambient conditions and can be applied for one-pot gram-scale synthesis.

Evaluation of the learning curve of laser peripheral iridectomy: the 20th case reaches the turning point.

AIM: To explore the learning curve for ophthalmologists at the start of laser peripheral iridectomy (LPI) training. METHODS: The learning curve of 4 doctor groups without previous LPI experience was studied. Three main parameters of LPI were reviewed: total energy, argon energy and neodymium-doped yttrium aluminum garnet (Nd:YAG) energy. Procedures were evaluated in cohorts of 20 cases to identify the turning points of the three variables. RESULTS: There was no significant difference in terms of age or eye among the 4 doctor groups. There were stable trends on the learning curve for the Doctor A and C groups regarding total energy and argon energy. In addition, the turning points on the learning curve were determined after the 20th procedure for the Doctor B and D groups regarding total energy and argon energy. Moreover, the Nd:YAG energy was relatively stable since the first procedure. CONCLUSION: It requires approximately 20 procedures for a beginner to reach a turning point on the learning curve regarding LPI. It can serve as a point of reference or guideline for training beginners to perform LPI.

Improved Survival of Periviable Infants after Alteration of the Threshold of Viability by the Neonatal Resuscitation Program 2015.

Periviable infants (PIs) born at 22-25 weeks gestational age (wGA) have a variable survival rate (49.7-86.2%) among hospitals. One factor involved in this difference may be the definition of the threshold of viability. The American Academy of Pediatrics revised the neonatal resuscitation program in late 2015 (NRP 2015) and altered the threshold of viability from 23 to 22 wGA. The impact on the survival of PIs after the guideline alteration has seldom been discussed. Since 2016, the unit of this study has implemented the renewed guideline for PIs. We retrospectively reviewed and analyzed the survival and clinical variables of PIs before and after implementation of the guideline, which included a 10-year cohort in a single center in Taiwan. There were 168 PIs enrolled between 2010 and 2019 (Epoch-I, 2010-2015; Epoch-II, 2016-2019), after excluding those with congenital anomalies and parent-decided comfort care. Compared to those in Epoch-I, the PIs in Epoch-II had significantly higher odds ratios (2.602) (95% confidence interval: 1.170-5.789; p = 0.019) for survival. Younger gestational age, small size for gestational age, cesarean delivery, low blood pH at birth, and surfactant therapeutic treatment were found to be significant risk factors associated with the survival of PIs (p < 0.05 for each). The altered threshold of viability by NRP 2015 may impact the survival of PIs. However, long-term follow-up for surviving PI is required in the future.

Frequent detection of anticoagulant rodenticides in raptors sampled in Taiwan reflects government rodent control policy.

Anticoagulant rodenticides (ARs) are known to cause extensive secondary exposure in top predators in Europe and North America, but there remains a paucity of data in Asia. In this study, we collected 221 liver samples from 21 raptor species in Taiwan between 2010 and 2018. Most birds were recovered from rescue organizations, but some free-ranging individuals were obtained from bird-strike prevention measures at airports. ARs were detected in 10 species and more than half of the total samples. Common rodent-eating Black-winged Kites (Elanus caeruleus) had the highest prevalence (89.2%) and highest average sum concentration (0.211 ±â€¯0.219 mg/kg), which was similar between free-ranging birds at airports and injured birds from rescue organizations. Scavenging Black Kites (Milvus migrans) and snake-eating Crested Serpent-eagles (Spilornis cheela) had the second highest prevalence or sum concentration, respectively. Seven different AR compounds were detected, of which brodifacoum was the most common and had the highest average concentration, followed by flocoumafen and bromadiolone. The frequency of occurrence in the three most numerous species (Black-winged Kite, Crested Goshawk [Accipiter trivirgatus], and Collared Scops-owl [Otus lettia]) was significantly higher in autumn than summer, which is consistent with the timing of the Taiwanese government's supply of free ARs to farmers. Regional differences in the detection of individual compounds also tended to reflect differences in human population density and use patterns (in agriculture or urban-dominated environments). Clinical poisoning was confirmed in Black Kites with sum concentrations as low as 0.026 mg/kg; however, further study of interspecific differences in AR sensitivity and potential population effects are needed. In addition, continued monitoring remains important given the Taiwanese government has modified their farmland rodent control policy to gradually reduce free AR supplies since 2015.

Frailty and anesthesia - risks during and post-surgery.

Frailty is a state of decreased physiologic reserve and resistance to stressors. Its prevalence increases with age and is estimated to be 26% in those aged above 85 years. As the population ages, frailty will be increasingly seen in surgical patients receiving anesthesia. Here, we evaluate the instruments which have been developed and validated for measuring frailty in surgical patients and summarize frailty tools used in 110 studies linking frailty status with adverse outcomes post-surgery. Frail older people are vulnerable to geriatric syndromes, and complications such as postoperative cognitive dysfunction and delirium are explored. This review also considers how frailty, with its decline of organ function, affects the metabolism of anesthetic agents and may influence the choice of anesthetic technique in an older person. Optimal perioperative care includes the identification of frailty, a multisystem and multidisciplinary evaluation preoperatively, and discussion of treatment goals and expectations. We conclude with an overview of the emerging evidence that Comprehensive Geriatric Assessment can improve postoperative outcomes and a discussion of the models of care that have been developed to improve preoperative assessment and enhance the postoperative recovery of older surgical patients.

The Effects of Rainfall, Temperature, and Wind on a Community of Montane Birds in Shei-Pa National Park, Taiwan.

Bruno A. Walther, Jane Ren-Jen Chen, Hui-Shan Lin, and Yuan-Hsun Sun (2017) Montane birds are regularly exposed to extreme weather variations. Taiwan's subtropical montane avifauna (which contains many endemic species) is regularly exposed to large weather fluctuations. From 2010 to 2013, we conducted monthly censuses to study the influence of monthly weather variations on species richness and bird density of a montane bird community (> 3000 m a. s. l.) in Shei-Pa National Park. Censuses were conducted along a trail which traverses four distinct habitats with increasing altitude: bush forest ecotone, post- re grassland, conifer forest, and rocky bushland. The highly variable weather corresponded with large fluctuations in the bird community. We found that lower temperatures had a negative effect on species richness and bird density, and this effect was strongest in the highest elevation habitat, the rocky bushland. Rainfall was positively correlated with bird density, but only explained 15% of the variation, while the effects of wind speed were inconsistent and small. This is the first study to demonstrate such weather effects in Taiwan and probably East Asia. We brie y discuss adaptations to harsh weather conditions in birds which could become a promising future research field for montane birds in Taiwan.

Screening in delirium: A pilot study of two screening tools, the Simple Query for Easy Evaluation of Consciousness and Simple Question in Delirium.

AIM: Delirium is poorly recognised and inadequately treated in medical settings. This research aimed to determine the psychometric properties of a newly developed tool, SQeeC against another emergent instrument, SQiD, in the screening of delirium. METHODS: The SQeeC was administered to 100 patients and SQiD administered to their informants in the general medical wards of a General Hospital. Data were compared with the reference standard geriatric consultant assessment of delirium. RESULTS: Compared with the reference standard, the SQeeC was found to have a sensitivity of 83% (95% CI 52-98%) and a specificity of 81% (95% CI 72-89%) with a negative predictive value of 97% (95% CI 90-100%) while the SQiD was found to have a sensitivity of 77% (95% CI 56-91%), a specificity of 51% (95% CI 37-64%) and a negative predictive value of 83% (95% CI 66-93%). CONCLUSION: The SQeeC and SQiD are simple and time efficient screening tools with encouraging psychometric properties.