Comprehensive geriatric assessment in perioperative care: a protocol for a systematic review and qualitative synthesis

INTRODUCTION: Comprehensive geriatric assessment (CGA) is an intervention that has been deployed in the perioperative setting with the aim to improve outcomes for older patients admitted to hospital. Older patients undergoing surgery are more likely to have postoperative complications, a longer hospital stay and be discharged to a care facility. Despite the increasing application of this intervention within surgical services, the evidence for CGA remains limited in this group. The aim of this systematic review is to describe CGA as in intervention applied to surgical populations in randomised controlled trials (RCTs) as well as the outcomes assessed. METHODS AND ANALYSIS: A systematic search of RCTs of CGA in surgery will be run in Embase, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Cochrane library. Further articles will be identified from reference lists in relevant studies found in the search. A narrative synthesis will be undertaken outlining specialties included, detailed descriptions of the intervention and outcomes. ETHICS AND DISSEMINATION: No ethical approval is required. The results of this review will be published and used as the basis of work to optimise this intervention for future trials in surgical populations. PROSPERO REGISTRATION NUMBER: This review is registered with PROSPERO CRD42020221797

The Lifetime and Powers of FR IIs in Galaxy Clusters

We have identified and studied a sample of 151 FR IIs found in brightest cluster galaxies (BCGs) in the MaxBCG cluster catalog with data from FIRST and NVSS. We have compared the radio luminosities and projected lengths of these FR IIs to the projected length distribution of a range of mock catalogs generated by an FR II model and estimate the FR II lifetime to be 1.9 x 10^8 yr. The uncertainty in the lifetime calculation is a factor of two, due primarily to uncertainties in the ICM density and the FR II axial ratio. We furthermore measure the jet power distribution of FR IIs in BCGs and find that it is well described by a log-normal distribution with a median power of 1.1 x 10^37 W and a coefficient of variation of 2.2. These jet powers are nearly linearly related to the observed luminosities, and this relation is steeper than many other estimates, although it is dependent on the jet model. We investigate correlations between FR II and cluster properties and find that galaxy luminosity is correlated with jet power. This implies that jet power is also correlated with black hole mass, as the stellar luminosity of a BCG should be a good proxy for its spheroid mass and therefore the black hole mass. Jet power, however, is not correlated with cluster richness, nor is FR II lifetime strongly correlated with any cluster properties. We calculate the enthalpy of the lobes to examine the impact of the FR IIs on the ICM and find that heating due to adiabatic expansion is too small to offset radiative cooling by a factor of at least six. In contrast, the jet power is approximately an order of magnitude larger than required to counteract cooling. We conclude that if feedback from FR IIs offsets cooling of the ICM, then heating must be primarily due to another mechanism associated with FR II expansion.Comment: 22 pages, 20 figures. Accepted to ApJ. Added minor clarifications throughout the paper and restructured section 6.2 in response to the referee. A brief video explaining the paper can be found at http://youtu.be/DOq85qUSU-

Prior Routine use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Important Outcomes in Hospitalised Patients with COVID-19

Acknowledgments: We gratefully acknowledge the collaborators of the study listed below: Ross Alexander, Emma Bhatti, Carly Bisset, Alice Cavenagh, Jemima Collins, Charlotte Davey, Siobhan Duffy, Jenny Edwards, Alice G Einarsson, Norman Galbraith, Madeline Garcia, James Hesford, Mark Holloway, Tarik Jichi, Joanna Kelly, Sheila Jones, Thomas Kneen, Thomas Lee, Kiah Lunstone, Emma Mitchell, Dolcie Paxton, Lyndsay Pearce, Terence J Quinn, Frances Rickard, Shefali Sangani, Rebecca Simmons, Sandeep Singh, Charlotte Silver, Thomas Telford, Alessia Verduri.Peer reviewedPublisher PD

Study protocol for the COPE study: COVID-19 in Older People : the influence of frailty and multimorbidity on survival. A multi-centre, European observational study

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.Peer reviewedPublisher PD

The Randomised Evaluation of early topical Lidocaine patches In Elderly patients admitted to hospital with rib Fractures (RELIEF): feasibility trial protocol

Background: Topical lidocaine patches, applied over rib fractures, have been suggested as a non-invasive method of local anaesthetic delivery to improve respiratory function, reduce opioid consumption and consequently reduce pulmonary complications. Older patients may gain most benefit from improved analgesic regimens yet lidocaine patches are untested as an early intervention in the Emergency Department (ED). The aim of this trial is to investigate uncertainties around trial design and conduct, to establish whether a definitive randomised trial of topical lidocaine patches in older patients with rib fractures is feasible. Methods: RELIEF is an open label, multicentre, parallel group, individually randomised, feasibility randomised controlled trial with economic scoping and nested qualitative study. Patients aged ≥ 65 years presenting to the ED with traumatic rib fracture(s) requiring admission will be randomised 1:1 to lidocaine patches (intervention), in addition to standard clinical management, or standard clinical management alone. Lidocaine patches will be applied immediately after diagnosis in ED and continued daily for 72 hours or until discharge. Feasibility outcomes will focus on recruitment, adherence and follow-up data with a total sample size of 100. Clinical outcomes, such as 30-day pulmonary complications, and resource use will be collected to understand feasibility of data collection. Qualitative interviews will explore details of the trial design, trial acceptability and recruitment processes. An evaluation of the feasibility of measuring health economics outcomes data will be completed. Discussion: Interventions to improve outcomes in elderly patients with rib fractures are urgently required. This feasibility trial will test a novel early intervention which has the potential of fulfilling this unmet need. The Randomised Evaluation of early topical Lidocaine patches In Elderly patients admitted to hospital with rib Fractures (RELIEF) feasibility trial will determine whether a definitive trial is feasible. ISRCTN Registration: ISRCTN14813929 (22/04/2021)

The effect of frailty on survival in patients with COVID-19 (COPE) : a multicentre, European, observational cohort study

Peer reviewedPublisher PD

Routine Use of Immunosuppressants is Associated with Mortality in Hospitalised Patients with Covid-19

Acknowledgement We acknowledge the dedication, commitment, and sacrifice of the staff from participating centres across UK and Italy, two among the most severely affected countries in Europe. We gratefully acknowledge the contribution of our collaborators, National Institute of Health Research (NIHR), Health Research Authority (HRA) in the UK and Ethics Committee of Policlinico Hospital Modena, which provided rapid approval of COPE study and respective Institutions’ Research and Development Offices and Caldicott Guardians for their assistance and guidance. We also thank COPE Study Sponsor, Cardiff University, Wales, UK.Peer reviewedPublisher PD

The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study

Background The COVID-19 pandemic has placed unprecedented strain on health-care systems. Frailty is being used in clinical decision making for patients with COVID-19, yet the prevalence and effect of frailty in people with COVID-19 is not known. In the COVID-19 in Older PEople (COPE) study we aimed to establish the prevalence of frailty in patients with COVID-19 who were admitted to hospital and investigate its association with mortality and duration of hospital stay. Methods This was an observational cohort study conducted at ten hospitals in the UK and one in Italy. All adults (≥18 years) admitted to participating hospitals with COVID-19 were included. Patients with incomplete hospital records were excluded. The study analysed routinely generated hospital data for patients with COVID-19. Frailty was assessed by specialist COVID-19 teams using the clinical frailty scale (CFS) and patients were grouped according to their score (1–2=fit; 3–4=vulnerable, but not frail; 5–6=initial signs of frailty but with some degree of independence; and 7–9=severe or very severe frailty). The primary outcome was in-hospital mortality (time from hospital admission to mortality and day-7 mortality). Findings Between Feb 27, and April 28, 2020, we enrolled 1564 patients with COVID-19. The median age was 74 years (IQR 61–83); 903 (57·7%) were men and 661 (42·3%) were women; 425 (27·2%) had died at data cutoff (April 28, 2020). 772 (49·4%) were classed as frail (CFS 5–8) and 27 (1·7%) were classed as terminally ill (CFS 9). Compared with CFS 1–2, the adjusted hazard ratios for time from hospital admission to death were 1·55 (95% CI 1·00–2·41) for CFS 3–4, 1·83 (1·15–2·91) for CFS 5–6, and 2·39 (1·50–3·81) for CFS 7–9, and adjusted odds ratios for day-7 mortality were 1·22 (95% CI 0·63–2·38) for CFS 3–4, 1·62 (0·81–3·26) for CFS 5–6, and 3·12 (1·56–6·24) for CFS 7–9. Interpretation In a large population of patients admitted to hospital with COVID-19, disease outcomes were better predicted by frailty than either age or comorbidity. Our results support the use of CFS to inform decision making about medical care in adult patients admitted to hospital with COVID-19

The RELIEF feasibility trial: Topical lidocaine patches in older adults with rib fractures

Background: Lidocaine patches, applied over rib fractures, may reduce pulmonary complications in older patients. Known barriers to recruiting older patients in emergency settings necessitate a feasibility trial. We aimed to establish whether a definitive randomised controlled trial (RCT) evaluating lidocaine patches in older patients with rib fracture(s) was feasible. Methods: This was a multicentre, parallel-group, open-label, feasibility RCT in seven hospitals in England and Scotland. Patients aged ≥65 years, presenting to ED with traumatic rib fracture(s) requiring hospital admission were randomised to receive up to 3×700 mg lidocaine patches (Ralvo), first applied in ED and then once daily for 72 hours in addition to standard care, or standard care alone. Feasibility outcomes were recruitment, retention and adherence. Clinical end points (pulmonary complications, pain and frailty-specific outcomes) and patient questionnaires were collected to determine feasibility of data collection and inform health economic scoping. Interviews and focus groups with trial participants and clinicians/research staff explored the understanding and acceptability of trial processes. Results: Between October 23, 2021 and October 7, 2022, 206 patients were eligible, of whom 100 (median age 83 years; IQR 74–88) were randomised; 48 to lidocaine patches and 52 to standard care. Pulmonary complications at 30 days were determined in 86% of participants and 83% of expected 30-day questionnaires were returned. Pulmonary complications occurred in 48% of the lidocaine group and 59% in standard care. Pain and some frailty-specific outcomes were not feasible to collect. Staff reported challenges in patient compliance, unfamiliarity with research measures and overwhelming the patients with research procedures. Conclusion: Recruitment of older patients with rib fracture(s) in an emergency setting for the evaluation of lidocaine patches is feasible. Refinement of data collection, with a focus on the collection of pain, frailty-specific outcomes and intervention delivery are needed before progression to a definitive trial. Trial registration number: ISRCTN14813929

Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma

Introduction: A common neurosurgical condition, chronic subdural haematoma (cSDH) typically affects older people with other underlying health conditions. The care of this potentially vulnerable cohort is often, however, fragmented and suboptimal. In other complex conditions, multidisciplinary guidelines have transformed patient experience and outcomes, but no such framework exists for cSDH. This paper outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH. Methods: The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement. Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework. The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents. Conclusions: We present a protocol for the development of a multidisciplinary guideline to inform the care of patients with a cSDH, developed by cross-disciplinary working groups and arrived at through a consensus-building process, including a modified online Delphi.</p