Silver Book II: an international framework for urgent care of older people in the first 72 hours from illness or injury.

The new edition of the Silver Book, Silver Book II, provides a framework for the urgent care of older people in the first 72 hours from illness or injury. It incorporates principles of geriatric medicine, quality improvement (including patient reported outcome measures) and interdisciplinary care in a balanced, practical and evidence-rich manual on unscheduled and emergent care for older adults. Silver Book II shows how frailty, comprehensive geriatric assessment and shared decision-making can be locally adapted according to national practice and policy across the world. The challenge for all providers is adapting our models of care to meet the changing needs of older patients and their caregivers as well as changes in the delivery of medical care in the 21st century.

Stress-induced TDP-43 nuclear condensation causes splicing loss of function and STMN2 depletion.

TDP-43 protein is dysregulated in several neurodegenerative diseases, which often have a multifactorial nature and may have extrinsic stressors as a "second hit." TDP-43 undergoes reversible nuclear condensation in stressed cells including neurons. Here, we demonstrate that stress-inducible nuclear TDP-43 condensates are RNA-depleted, non-liquid assemblies distinct from the known nuclear bodies. Their formation requires TDP-43 oligomerization and ATP and is inhibited by RNA. Using a confocal nanoscanning assay, we find that amyotrophic lateral sclerosis (ALS)-linked mutations alter stress-induced TDP-43 condensation by changing its affinity to liquid-like ribonucleoprotein assemblies. Stress-induced nuclear condensation transiently inactivates TDP-43, leading to loss of interaction with its protein binding partners and loss of function in splicing. Splicing changes are especially prominent and persisting for STMN2 RNA, and STMN2 protein becomes rapidly depleted early during stress. Our results point to early pathological changes to TDP-43 in the nucleus and support therapeutic modulation of stress response in ALS.

Cymoxanil disrupts RNA synthesis through inhibiting the activity of dihydrofolate reductase.

The agricultural fungicide cymoxanil (CMX) is commonly used in the treatment of plant pathogens, such as Phytophthora infestans. Although the use of CMX is widespread throughout the agricultural industry and internationally, the exact mechanism of action behind this fungicide remains unclear. Therefore, we sought to elucidate the biocidal mechanism underlying CMX. This was accomplished by first performing a large-scale chemical-genomic screen comprising the 4000 haploid non-essential gene deletion array of the yeast Saccharomyces cerevisiae. We found that gene families related to de novo purine biosynthesis and ribonucleoside synthesis were enriched in the presence of CMX. These results were confirmed through additional spot-test and colony counting assays. We next examined whether CMX affects RNA biosynthesis. Using qRT-PCR and expression assays, we found that CMX appears to target RNA biosynthesis possibly through the yeast dihydrofolate reductase (DHFR) enzyme Dfr1. To determine whether DHFR is a target of CMX, we performed an in-silico molecular docking assay between CMX and yeast, human, and P. infestans DHFR. The results suggest that CMX directly interacts with the active site of all tested forms of DHFR using conserved residues. Using an in vitro DHFR activity assay we observed that CMX inhibits DHFR activity in a dose-dependent relationship.

Utility of head computed tomography for older adults with suspected delirium in the emergency department: A retrospective observational study.

BACKGROUND: Delirium in older people is associated with significant morbidity and mortality and has life-threatening etiologies making prompt recognition essential. Computed tomography of the head (CT-head) may have a role in determining the cause of delirium; however, inpatient studies suggest it is overused. There is a paucity of emergency department (ED)-based research surrounding the use of CT-head in delirium. This study aims to describe the utility of CT-head in older patients presenting to the ED with symptoms of delirium. METHODS: We conducted a retrospective chart review of patients 65 years and older with symptoms of delirium who visited local EDs over a 3.5-year period (2016-2020). We compared patients who did and did not receive CT-head. Our primary objective was to determine the proportion of acute findings in patients who received CT-head. Our secondary objectives were to describe the proportions of patients who did and did not receive CT-head in terms of their demographics, presenting symptoms, disposition, and indications for and results of CT-head scans. Chi-square tests were utilized for comparisons. RESULTS: A total of 630 encounters were identified through database searching; 526 met inclusion criteria. Thirty-four were excluded for presenting directly to consultants, leaving 492 included encounters. Of those who received a CT-head (n = 279), 13 (4.7%) had acute findings. Of the encounters with acute findings, four (30.77%) had focal neurological deficits (FND), and two (15.38%) had Glasgow Coma Scale (GCS) score < 14. Patients without CT-head (n = 213) were more likely to be discharged (p < 0.01) and less likely to have a FND (p < 0.01). CONCLUSIONS: CT-head is ordered for over half of older ED patients with symptoms of delirium despite infrequent acute findings. Acute findings typically occur in the context of symptoms suggestive of intracranial abnormalities such as FND or GCS < 14. This suggests physicians should be more selective when ordering CT-heads in patients with symptoms of delirium.

The Association Between Frailty and a Nurse-Identified Need for Comprehensive Geriatric Assessment Referral from the Emergency Department.

BACKGROUND: Emergency nurses commonly conduct geriatric assessments in the emergency department (ED). However, little is known about what geriatric syndromes or clinical presentations prompt a nurse to document an identified need for comprehensive geriatric assessment (CGA). OBJECTIVES: To examine the association between geriatric syndromes, like frailty, and a nurse-identified need for a CGA following emergency care. METHODS: We conducted a secondary analysis of a multi-province Canadian cohort from the InterRAI Multinational Cohort Study. We collected data at ED registration from patients 75 years of age and older (n = 2,274) from eight ED sites across Canada between November 2009 and April 2012. Geriatric syndromes were assessed by trained emergency nurses using the interRAI ED Contact Assessment; and we retrospectively calculated the ED frailty index. We employed binary logistic regression to determine the adjusted associations between geriatric syndromes and a nurse-identified need for a CGA. RESULTS: Approximately one-quarter (28%) of older adults were identified to need a CGA following emergency care. A 0.1 unit increase in the ED frailty index increased the likelihood of a nurse identify a need for CGA (RD: 6.6; 95% CI = 5.5-7.9). Most geriatric syndromes increased the probability of a nurse documenting the need for a CGA. CONCLUSION: When assessed by emergency nurses, the identified need for CGA is strongly linked to the presence of geriatric syndromes, including frailty. We provide face validity for the continued use of emergency nurses for screening and assessing older ED patients.

Using volunteers to improve the experience of older patients in the emergency department.

OBJECTIVES: The Maximizing Aging Using Volunteer Engagement in the Emergency Department (MAUVE + ED) program connects specially trained volunteers with older patients whose personal and social needs are not always met within the busy ED environment. The objective of this study was to describe the development and implementation of the MAUVE + ED program. METHODS: Volunteers were trained to identify and approach older patients at risk for adverse outcomes, including poor patient experience, and invite such patients to participate in the program. The program is available to all patients >65 years, and those with confusion, patients who were alone, those with mobility issues, and patients with increased length of stay in the ED. Volunteers documented their activities after each patient encounter using a standardized paper-based data collection form. RESULTS: Over the program's initial 6-month period, the MAUVE + ED volunteers reported a total of 896 encounters with 718 unique patients. The median time (interquartile range [IQR]) a MAUVE volunteer spent with a patient was 10 minutes (IQR = 5, 20), with a range of 1 to 130 minutes. The median number of patients seen per shift was 7 (IQR = 6, 9), with a range of 1 to 16 patients per shift. The most common activities the volunteer assisted with were therapeutic activities/social visits (n = 859; 95.9%), orientation activities (n = 501; 55.9%), and hydration assistance (n = 231; 25.8%). The least common were mobility assistance (n = 36; 4.0%), and vision/hearing assistance (n = 13; 1.5%). CONCLUSIONS: Preliminary data suggest the MAUVE + ED volunteers were able to provide additional care to older adults and their families/carers in the ED.

Register to donate while you wait: Assessing public opinions of the acceptability of utilizing the emergency department waiting room for organ and tissue donor registration.

OBJECTIVE: Our objectives were to identify barriers to the organ donation registration process in Ontario; and to determine the acceptability of using the emergency department (ED) waiting room to provide knowledge and offer opportunities for organ and tissue donor registration. METHODS: We conducted a paper based in-person survey over nine days in March and April 2017. The survey instrument was created in English using existing literature and expert opinion, pilot tested and then translated into French. Data was collected from patients and visitors in an urban academic Canadian tertiary care ED waiting room. All adults in the waiting room were approached to participate during study periods. We excluded patients who were too ill and required immediate treatment. RESULTS: The number of attempted surveys was 324; 67 individuals (20.7%) declined participation. A total of 257 surveys were distributed and five were returned blank. This gave us a response rate of 77.8% with 252 completed surveys. The median age group was 51-60 years old with 55.9% female. Forty-six percent reported their religion as Christian and 34.1% did not declare a religious affiliation. 44.1% were already registered donors. Most participants agreed or were neutral that the ED waiting room was an acceptable place to provide information on donation, and for registration as an organ and tissue donor (83.3% and 82.1%, respectively). CONCLUSIONS: Individuals waiting in the ED are generally supportive of using the waiting room for distributing information regarding organ and tissue donation, and to allow donor registration.

CONTEXTE: L'étude avait pour objectifs : 1) de relever les obstacles au processus d'inscription du don d'organes en Ontario; 2) de déterminer l'acceptabilité sociale de l'utilisation de la salle d'attente du service des urgences (SU) comme lieu de diffusion de l'information sur les dons de matériel biologique, et d'inscription de donneurs d'organes et de tissus. MÉTHODE: Une enquête a été menée en personne, au moyen d'un questionnaire sur papier, durant 9 jours, en mars et en avril 2017. L'instrument d'enquête a d'abord été élaboré en anglais à l'aide de la documentation existante et de l'avis d'experts, puis soumis à un essai pilote avant d'être traduit en français. La collecte de données s'est faite parmi les patients et les personnes qui les accompagnaient dans une salle d'attente d'un SU d'enseignement, de soins tertiaires, situé en milieu urbain, au Canada. Tous les adultes présents dans la salle d'attente ont été invités à participer à l'étude durant la période en question. Ont été exclus les patients qui étaient trop malades ou dont l'état nécessitait des soins immédiats. RÉSULTATS: Il y a eu 324 demandes d'enquête et 67 personnes (20,7%) ont refusé de participer. Sur un total de 257 questionnaires remis, 5 ont été rendus vierges, ce qui a porté à 77,8% (252 questionnaires remplis) le taux de réponse. L'âge médian était de 51­60 ans, et 55,9% des répondants étaient des femmes. Quarante-six pour cent des participants se sont déclarés chrétiens et 34,1% n'ont rien indiqué quant à leur appartenance religieuse; par ailleurs, 44,1% étaient déjà des donneurs inscrits. La plupart des répondants se sont montrés favorables ou neutres à l'égard de l'utilisation de la salle d'attente du SU comme lieu de diffusion de l'information sur les dons de matériel biologique, ou d'inscription de donneurs d'organes et de tissus (83,3% et 82,1%, respectivement). CONCLUSION: Dans l'ensemble, les personnes interrogées au SU se sont montrées favorables à l'utilisation de la salle d'attente comme lieu de diffusion de l'information sur les dons d'organes et de tissus, et d'inscription de donneurs.

Solid organ donation from the emergency department - A systematic review.

OBJECTIVES: A significant gap exists between people awaiting an organ transplant and organ donors. The purpose of this study was to determine what percent of successful donors come from the emergency department (ED), whether there are any missed donors, and to identify factors associated with successful and missed donation. METHODS: This systematic review used electronic searches of EMBASE, MEDLINE, and CINAHL according to PRISMA guidelines on July 7, 2017. We included primary literature in adults describing successful and missed organ donation. Two authors independently screened articles, and discrepancies were resolved through consensus. Quality was assessed using the STROBE checklist. RESULTS: This systematic review identified 1,058 articles, and 25 articles were included. For neurologic determination of death, ED patients comprised 4%-50% of successful donors and 3.6%-8.9% of successful donors for donation after circulatory determination of death. ED death reviews revealed up to 84% of missed neurologic determination of death, and 46.2% of missed circulatory determination of death donors who died in the ED are missed due to a failure to refer for consideration of organ donation. Clinical heterogeneity precluded pooling of the data to conduct a meta-analysis. CONCLUSIONS: The ED is a source of actual and missed donors. Potential donors are often missed due to incorrect assumptions regarding eligibility criteria and failure of the healthcare team to refer for consideration of donation. ED healthcare professionals should be aware of organ donation referral protocols at their institution to ensure that no organ donors are missed.

OBJECTIF: Il existe un écart important entre le nombre de malades dans l'attente d'une transplantation d'organe et celui de donneurs d'organes. L'étude avait donc pour but de déterminer le pourcentage de donneurs effectifs qui proviennent du service des urgences (SU), le risque de non-repérage des donneurs potentiels et les facteurs associés aux dons effectifs ou manqués d'organes. MÉTHODE: Une revue systématique consistant en une recherche électronique dans les bases de données EMBASE, MEDLINE et CINAHL a été menée selon les lignes directrices PRISMA, le 7 juillet 2017. Ont été retenus des articles de première main faisant étant du repérage ou non des donneurs potentiels d'organes chez les adultes. Deux auteurs ont examiné, chacun de leur côté, les articles, et les divergences de points de vue ont été résolues par voie de consensus. La qualité des études a été évaluée à l'aide de la liste de vérification STROBE. RÉSULTATS: La revue systématique a permis de dégager 1058 articles, dont 25 ont été retenus. Les patients au SU représentaient de 4 à 50% des donneurs effectifs en ce qui concerne les cas de mort cérébrale, et de 3,6 à 8,9% des donneurs effectifs en ce qui concerne les cas de mort cardiocirculatoire. D'après l'examen des causes de décès au SU, le taux de non-repérage des donneurs potentiels pouvait atteindre 84% dans les cas de mort cérébrale et 46,2% dans les cas de mort cardiocirculatoire, la situation s'expliquant par le manque de consultations des ressources en dons éventuels d'organes. Enfin, il n'a pas été possible de procéder à une méta-analyse en raison de l'hétérogénéité des données cliniques qui faisait obstacle à leur mise en commun. CONCLUSION: Le SU est une source à la fois effective et non identifiée de donneurs d'organes. Souvent, les donneurs potentiels ne sont pas repérés en raison d'une perception erronée des critères d'admissibilité et du manque de consultations, par l'équipe de soins, des ressources en dons éventuels d'organes. Les professionnels de la santé au SU devraient donc être bien informés des protocoles de consultation des ressources en la matière dans leur établissement afin d'éviter le non-repérage des donneurs potentiels.

Climbing ability of teneral and sclerotized adult bed bugs and assessment of adhesive properties of the exoskeletal fluid using atomic force microscopy.

We observed that teneral adults (<1 h post-molt) of Cimex lectularius L. appeared more adept at climbing a smooth surface compared to sclerotized adults. Differences in climbing ability on a smooth surface based on sclerotization status were quantified by measuring the height to which bed bugs climbed when confined within a glass vial. The average maximum height climbed by teneral (T) bed bugs (n = 30, height climbed = 4.69 cm) differed significantly (P< 0.01) from recently sclerotized (RS) bed bugs (n = 30, height climbed = 1.73 cm at ~48 h post molt), sclerotized group 1 (S1) bed bugs (n = 30, S1 = 2.42 cm at >72 h), and sclerotized group 2 (S2) bed bugs (n = 30, height climbed = 2.64 cm at >72 h post molt). When heights from all climbing events were summed, teneral bed bugs (650.8 cm climbed) differed significantly (P< 0.01) from recently sclerotized (82 cm climbed) and sclerotized (group 1 = 104.6 cm climbed, group 2 = 107.8 cm climbed) bed bugs. These findings suggested that the external surface of teneral bed bug exoskeletons possess an adhesive property. Using atomic force microscopy (AFM), we found that adhesion force of an exoskeletal (presumably molting) fluid decreased almost five-fold from 88 to 17 nN within an hour of molting. Our findings may have implications for laboratory safety and the effectiveness of bed bug traps, barriers, and biomimetic-based adhesives.