Using the 5Ms Framework to Advance Aging-Responsive Care for Heart Failure with Reduced Ejection Fraction

Abigail Latimer,1 Debra K Moser,2 Jia-Rong Wu,2 Kim K Birtcher,3 Malachy J Clancy,4 Jennifer D Portz,5 Joanna Paladino,6,7 Daniel D Matlock,8,9 Christopher E Knoepke10 1College of Social Work, University of Kentucky, Lexington, KY, 40506, USA; 2College of Nursing, University of Tennessee Knoxville, Knoxville, TN, 37996, USA; 3College of Pharmacy, University of Houston, Houston, TX, 77204, USA; 4Department of Occupational Therapy, Thomas Jefferson University, Philadelphia, PA, 19107, USA; 5University of Colorado Anschutz, General Internal Medicine, Aurora, CO, 80045, USA; 6Massachusetts General Hospital, Boston, MA, 02114, USA; 7Harvard Medical School, Boston, MA, 02115, USA; 8Department of Medicine, Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA; 9VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, 80045, USA; 10Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, 80045, USACorrespondence: Abigail Latimer, College of Social Work, University of Kentucky, 619 Patterson Office Tower, #533, Lexington, KY, 40506, USA, Email [email protected]: Complexity of care is the inevitable consequence of an aging population and is particularly true in instances where patients are managing chronic conditions such as heart failure with reduced ejection fraction (HFrEF). HFrEF itself is complex, with an undulating course of illness, increased risk of sudden cardiac death, and myriad accompanying treatment considerations. Generalist management of HFrEF among older patients is further complicated by competing comorbidities, potential for financial toxicity, potential for mental health symptoms, and risk of care with does not align with goals and preferences. The 5Ms (multicomplexity, mind, mobility, medications, and matters most) is a holistic conceptualization of care that has been applied to the care of older adults, including in gastroenterology, ICU care, oncology, and dentistry. In this narrative review, we present 5Ms Model of care for older adults with HFrEF.Keywords: older adult, cardiovascular disease, interprofessional, interdisciplinary, framewor

Recovery in Stroke Rehabilitation through the Rotation of Preferred Directions Induced by Bimanual Movements: A Computational Study

Stroke patients recover more effectively when they are rehabilitated with bimanual movement rather than with unimanual movement; however, it remains unclear why bimanual movement is more effective for stroke recovery. Using a computational model of stroke recovery, this study suggests that bimanual movement facilitates the reorganization of a damaged motor cortex because this movement induces rotations in the preferred directions (PDs) of motor cortex neurons. Although the tuning curves of these neurons differ during unimanual and bimanual movement, changes in PD, but not changes in modulation depth, facilitate such reorganization. In addition, this reorganization was facilitated only when encoding PDs are rotated, but decoding PDs are not rotated. Bimanual movement facilitates reorganization because this movement changes neural activities through inter-hemispheric inhibition without changing cortical-spinal-muscle connections. Furthermore, stronger inter-hemispheric inhibition between motor cortices results in more effective reorganization. Thus, this study suggests that bimanual movement is effective for stroke rehabilitation because this movement rotates the encoding PDs of motor cortex neurons

Chiropractic and exercise for seniors with low back pain or neck pain: the design of two randomized clinical trials

BACKGROUND: Low back pain (LBP) and neck pain (NP) are common conditions in old age, leading to impaired functional ability and decreased independence. Manual and exercise therapies are common and effective therapies for the general LBP and NP populations. However, these treatments have not been adequately researched in older LBP and NP sufferers.The primary aim of these studies is to assess the relative clinical effectiveness of 1) manual treatment plus home exercise, 2) supervised rehabilitative exercise plus home exercise, and 3) home exercise alone, in terms of patient-rated pain, for senior LBP and NP patients. Secondary aims are to compare the three treatment approaches in regards to patient-rated disability, general health status, satisfaction, improvement and medication use, as well as objective outcomes of spinal motion, trunk strength and endurance, and functional ability. Cost-effectiveness and cost-utility will also be assessed. Finally, using qualitative methods, older LBP and NP patient's perceptions of treatment will be explored and described. METHODS/DESIGN: This paper describes the design of two multi-methods clinical studies focusing on elderly patients with non-acute LBP and NP. Each study includes a randomized clinical trial (RCT), a cost-effectiveness study alongside the RCT, and a qualitative study. Four hundred and eighty participants (240 per study), ages 65 and older, will be recruited and randomized to one of three, 12-week treatment programs. Patient-rated outcome measures are collected via self-report questionnaires at baseline and at 4, 12, 26, and 52 weeks post-randomization. Objective outcomes are assessed by examiners masked to treatment assignment at baseline and 12 weeks. Health care cost data is collected through standardized clinician forms, monthly phone interviews, and self-report questionnaires throughout the study. Qualitative interviews using a semi-structured format are conducted at the end of the 12 week treatment period. DISCUSSION: To our knowledge, these are the first randomized clinical trials to comprehensively address clinical effectiveness, cost-effectiveness, and patients' perceptions of commonly used treatments for elderly LBP and NP sufferers

The immediate and long-term effects of exercise and patient education on physical, functional, and quality-of-life outcome measures after single-level lumbar microdiscectomy: a randomized controlled trial protocol

BACKGROUND: Low back pain remains a costly quality-of-life-related health problem. Microdiscectomy is often the surgical procedure of choice for a symptomatic, single-level, lumbar disc herniation in younger and middle-aged adults. The question of whether a post-microdiscectomy exercise program enhances function, quality of life, and disability status has not been systematically explored. Thus, the overall purpose of this study is to assess immediate and long-term outcomes of an exercise program, developed at University of Southern California (USC), targeting the trunk and lower extremities (USC Spine Exercise Program) for persons who have undergone a single-level microdiscectomy for the first time. METHODS/DESIGN: One hundred individuals between the ages of 18 and 60 who consent to undergo lumbar microdiscectomy will be recruited to participate in this study. Subjects will be randomly assigned to one of two groups: 1) one session of back care education, or 2) a back care education session followed by the 12-week USC Spine Exercise Program. The outcome examiners (evaluators), as well as the data managers, will be blinded to group allocation. Education will consist of a one-hour "one-on-one" session with the intervention therapist, guided by an educational booklet specifically designed for post-microdiscectomy care. This session will occur four to six weeks after surgery. The USC Spine Exercise Program consists of two parts: back extensor strength and endurance, and mat and upright therapeutic exercises. This exercise program is goal-oriented, performance-based, and periodized. It will begin two to three days after the education session, and will occur three times a week for 12 weeks. Primary outcome measures include the Oswestry Disability Questionnaire, Roland-Morris Disability Questionnaire, SF-36(® )quality of life assessment, Subjective Quality of Life Scale, 50-foot Walk, Repeated Sit-to-Stand, and a modified Sorensen test. The outcome measures in the study will be assessed before and after the 12-week post-surgical intervention program. Long-term follow up assessments will occur every six months beginning one year after surgery and ending five years after surgery. Immediate and long-term effects will be assessed using repeated measures multivariate analysis of variance (MANOVA). If significant interactions are found, one-way ANOVAs will be performed followed by post-hoc testing to determine statistically significant pairwise comparisons. DISCUSSION: We have presented the rationale and design for a randomized controlled trial evaluating the effectiveness of a treatment regimen for people who have undergone a single-level lumbar microdiscectomy

Movement control exercise versus general exercise to reduce disability in patients with low back pain and movement control impairment. A randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>Non-specific low back pain (NSLBP) in subacute and chronic stages can be treated effectively with exercise therapy. Research guidelines recommend evaluating different treatments in defined subgroups of patients with NSLBP. A subgroup of patients with movement control impairment (MCI) improved significantly on patient specific function and disability in a previous case series after movement control exercises.</p> <p>Methods/Design</p> <p>In a randomised controlled trial (RCT) we will compare the effectiveness of movement control and general exercise in patients with MCI. 106 participants aged 18 - 75 will be recruited in 5 outpatient hospital departments and 7 private practices.</p> <p>Patients randomly assigned to the movement control exercise group will be instructed to perform exercises according to their MCI. The general exercise group will follow an exercise protocol aimed at improving endurance and flexibility. Patients in both groups will receive 9 - 18 treatments and will be instructed to do additional exercises at home.</p> <p>The primary outcome is the level of disability assessed using the patient specific functional scale (PSFS) which links the perceived pain to functional situations and is measured before treatment and at 6 and 12 months follow-up. Secondary outcomes concern low back pain related disability (Roland Morris questionnaire, RMQ), graded chronic pain scale (GCPS), range of motion and tactile acuity.</p> <p>Discussion</p> <p>To our knowledge this study will be the first to compare two exercise programs for a specific subgroup of patients with NSLBP and MCI. Results of this study will provide insight into the effectiveness of movement control exercise and contribute to our understanding of the mechanisms behind MCI and its relation to NSLBP.</p> <p>Trial registration</p> <p>Current Controlled Trials <a href="http://www.controlled-trials.com/ISRCTN80064281">ISRCTN80064281</a></p

The evolutionary history of lethal metastatic prostate cancer

Cancers emerge from an ongoing Darwinian evolutionary process, often leading to multiple competing subclones within a single primary tumour. This evolutionary process culminates in the formation of metastases, which is the cause of 90% of cancer-related deaths. However, despite its clinical importance, little is known about the principles governing the dissemination of cancer cells to distant organs. Although the hypothesis that each metastasis originates from a single tumour cell is generally supported, recent studies using mouse models of cancer demonstrated the existence of polyclonal seeding from and interclonal cooperation between multiple subclones. Here we sought definitive evidence for the existence of polyclonal seeding in human malignancy and to establish the clonal relationship among different metastases in the context of androgen-deprived metastatic prostate cancer. Using whole-genome sequencing, we characterized multiple metastases arising from prostate tumours in ten patients. Integrated analyses of subclonal architecture revealed the patterns of metastatic spread in unprecedented detail. Metastasis-to-metastasis spread was found to be common, either through de novo monoclonal seeding of daughter metastases or, in five cases, through the transfer of multiple tumour clones between metastatic sites. Lesions affecting tumour suppressor genes usually occur as single events, whereas mutations in genes involved in androgen receptor signalling commonly involve multiple, convergent events in different metastases. Our results elucidate in detail the complex patterns of metastatic spread and further our understanding of the development of resistance to androgen-deprivation therapy in prostate cancer.This is an ICGC Prostate Cancer study funded by: Cancer Research UK (2011-present); NIH NCI Intramural Program (2013-2014); Academy of Finland (2011-present); Cancer Society of Finland (2013-present); PELICAN Autopsy Study family members and friends (1998-2004); John and Kathe Dyson (2000); US National Cancer Institute CA92234 (2000-2005); American Cancer Society (1998-2000); Johns Hopkins University Department of Pathology (1997-2011); Women's Board of Johns Hopkins Hospital (1998); The Grove Foundation (1998); Association for the Cure of Cancer of the Prostate (1994-1998); American Foundation for Urologic Disease (1991-1994); Bob Champion Cancer Trust (2013-present); Research Foundation – Flanders (FWO) [FWO-G.0687.12] (2012-present). E.P. is a European Hematology Association Research Fellow

A modified Delphi approach to standardize low back pain recurrence terminology

Lack of standardization of terminology in low back pain (LBP) research has significantly impeded progress in this area. The diversity in existing definitions for a ‘recurrence of an episode of LBP’ and ‘recurrent LBP’ is an important example. The variety of definitions used by researchers working in this area has prevented comparison of results between trials and made meta-analyses of this data unfeasible. The aim of this study was to use a modified Delphi approach to gain consensus on definitions for a ‘recurrence of an episode of LBP’ (e.g. outcome event) and for ‘recurrent LBP’ (e.g. patient population). Existing definitions for both constructs were classified into the main features comprising the definition (e.g. ‘duration of pain’) and the items that defined each feature (e.g. ‘pain lasting at least 24 h’). In each round, participants were asked to rate the importance of each feature to a definition of a ‘recurrence of an episode of LBP’, and a definition of ‘recurrent LBP’ and rank the items (defining each feature) in order of decreasing importance. Forty-six experts in LBP research, from nine different countries, participated in this study. Four rounds were completed with responses rates of 94, 91, 83, and 97% in rounds 1, 2, 3, and 4, respectively. Consensus definitions were reached in both areas with 95% of panel members supporting the definition of a ‘recurrence of an episode of LBP’ and 92% of panel members supporting the definition of ‘recurrent LBP’. Future research is necessary to evaluate these definitions

Foot strike patterns and collision forces in habitually barefoot versus shod runners

Humans have engaged in endurance running for millions of years, but the modern running shoe was not invented until the 1970s. For most of human evolutionary history, runners were either barefoot or wore minimal footwear such as sandals or moccasins with smaller heels and little cushioning relative to modern running shoes. We wondered how runners coped with the impact caused by the foot colliding with the ground before the invention of the modern shoe. Here we show that habitually barefoot endurance runners often land on the fore-foot (fore-foot strike) before bringing down the heel, but they sometimes land with a flat foot (mid-foot strike) or, less often, on the heel (rear-foot strike). In contrast, habitually shod runners mostly rear-foot strike, facilitated by the elevated and cushioned heel of the modern running shoe. Kinematic and kinetic analyses show that even on hard surfaces, barefoot runners who fore-foot strike generate smaller collision forces than shod rear-foot strikers. This difference results primarily from a more plantarflexed foot at landing and more ankle compliance during impact, decreasing the effective mass of the body that collides with the ground. Fore-foot- and mid-foot-strike gaits were probably more common when humans ran barefoot or in minimal shoes, and may protect the feet and lower limbs from some of the impact-related injuries now experienced by a high percentage of runners