Whole home exercise intervention for depression in older care home residents (the OPERA study) : a process evaluation

Background: The ‘Older People’s Exercise intervention in Residential and nursing Accommodation’ (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect. Methods: The OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known. Results: Homes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises. Conclusions: The intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms

Bone marrow stromal cells attenuate sepsis via prostaglandin E2— dependent reprogramming of host macrophages to increase their interleukin-10 production

Sepsis causes over 200,000 deaths yearly in the US; better treatments are urgently needed. Administering bone marrow stromal cells (BMSCs—also known as mesenchymal stem cells) to mice before or shortly after inducing sepsis by cecal ligation and puncture reduced mortality and improved organ function. The beneficial effect of BMSCs was eliminated by macrophage depletion or pretreatment with antibodies specific for interleukin-10 (IL-10) or IL-10 receptor. Monocytes and/ or macrophages from septic lungs made more IL-10 when prepared from mice treated with BMSCs versus untreated mice. Lipopolysaccharide (LPS)-stimulated macrophages produced more IL-10 when cultured with BMSCs, but this effect was eliminated if the BMSCs lacked the genes encoding Toll-like receptor 4, myeloid differentiation primary response gene-88, tumor necrosis factor (TNF) receptor-1a or cyclooxygenase-2. Our results suggest that BMSCs (activated by LPS or TNF-α) reprogram macrophages by releasing prostaglandin E2 that acts on the macrophages through the prostaglandin EP2 and EP4 receptors. Because BMSCs have been successfully given to humans and can easily be cultured and might be used without human leukocyte antigen matching, we suggest that cultured, banked human BMSCs may be effective in treating sepsis in high-risk patient groups.Sepsis, a serious medical condition that affects 18 million people per year worldwide, is characterized by a generalized inflammatory state caused by infection. Widespread activation of inflammation and coagulation pathways progresses to multiple organ dysfunction, collapse of the circulatory system (septic shock) and death. Because as many people die of sepsis annually as from acute myocardial infarction1, a new treatment regimen is desperately needed. In the last few years, it has been discovered that BMSCs are potent modulators of immune responses2-5. We wondered whether such cells could bring the immune response back into balance, thus attenuating the underlying pathophysiology that eventually leads to severe sepsis, septic shock and death6,7. As a model of sepsis, we chose cecal ligation and puncture (CLP), a procedure that has been used for more than two decades8. This mouse model closely resembles the human disease: it has a focal origin (cecum), is caused by multiple intestinal organisms, and results in septicemia with release of bacterial toxins into the circulation. With no treatment, the majority of the mice die 24-48 h postoperatively. Originally published Nature Medicine, Vol. 15, No. 1, Jan 200

The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72254/1/j.1460-9592.2005.01773.x.pd

Alabama Veterans Rural Health Initiative: A Preliminary Evaluation of Unmet Health Care Needs

The Alabama Veterans Rural Health Initiative aims to better understand the health care needs, health status, and barriers to care for rural veterans. Following extensive community outreach, Veteran Community Outreach Health Workers assessed 203 veterans residing in rural counties of Alabama who either: 1) had never enrolled in VA health services, or 2) had not used those services in at least two years. While 71.4 percent of participants reported having utilized non-VHA primary care within the past year, 33.5 percent reported an inability or delay in obtaining needed health care for one or more services: primary care, specialty care, mental health care, addictions treatment, dental care, or prescription medication. The most commonly cited barrier was cost. Among all participants, 56 percent screened positive for at least one Axis I mental disorder. Rurally residing, non-VHA utilizing veterans appear to have fairly good access to primary care, but need dental care, prescription medication, and mental health care

Evaluating the risk and risk factors of dysautonomia as a post-acute sequelae of COVID-19: a secondary analysis of a matched case–control dataset

BackgroundA significant proportion of patients presenting with post-acute sequelae of COVID-19 (PASC) have been found to meet diagnostic criteria for certain disorders of the autonomic nervous system. Substantial gaps remain in our understanding of these conditions. Our objective is to evaluate demographic and medical factors associated with PASC dysautonomia in active duty US Service members (ADSM). Additionally we assessed for risk factors in those diagnosed with COVID-19 for PASC dysautonomia, and differences in those with PASC dysautonomia and non-PASC dysautonomia.MethodsA matched case control dataset (n = 1,367,961) of ADSM diagnosed with COVID-19 matched with ADSM with no evidence of COVID-19 was utilized to assess associations of demographic and clinical factors with PASC dysautonomia. Logistic regression modeling was used to assess differences among those diagnosed with COVID-19. Conditional logistic regression modeling using propensity score weighting was used for comparisons between those with PASC dysautonomia and non-PASC dysautonomia.ResultsWe identified 619,983 COVID-19 cases (158 PASC dysautonomia) and 747,978 controls (219 non-PASC dysautonomia). Among COVID-19 cases, factors positively associated with PASC dysautonomia were white, non-Hispanic race/ethnicity, female sex, younger age, northeast region, more severe COVID-19 infection, and comorbid depression or anxiety. Among those with dysautonomia, those with PASC dysautonomia were more likely to be of female sex, younger, in the northeast region, and less likely to have comorbid anxiety.ConclusionPASC dysautonomia is rare in ADSM but associated with increased care utility and often prolonged diagnostic pathways. Important demographic and COVID-19 specific risk factors are associated with the development of PASC dysautonomia. PASC dysautonomia has significant differences in risk factors as compared to non-PASC dysautonomia, warranting further examination. These findings may support clinician awareness and prognostication and prompt further research on the pathophysiology and management of these conditions

Validation of Doloplus-2 among nonverbal nursing home patients - an evaluation of Doloplus-2 in a clinical setting

In the present study, more patients were categorized as having pain while using Doloplus-2 compared with nurses' estimation of pain without using any tools. The fact that nurses could not report if the patients were in pain in one third of the patients supports the claim that Doloplus-2 is a useful supplement for estimating pain in this population. However, nurses must use their clinical experience in addition to the use of Doloplus-2, as behaviour can have different meaning for different patients. Further research is still needed about the use of Doloplus-2 in patients not able to self-report their pain.THE WORK (AS DEFINED BELOW) IS PROVIDED UNDER THE TERMS OF THIS BIOMED CENTRAL OPEN ACCESS LICENSE ("LICENSE"). THE WORK IS PROTECTED BY COPYRIGHT AND/OR OTHER APPLICABLE LAW. ANY USE OF THE WORK OTHER THAN AS AUTHORIZED UNDER THIS LICENSE IS PROHIBITED.BY EXERCISING ANY RIGHTS TO THE WORK PROVIDED HERE, YOU ACCEPT AND AGREE TO BE BOUND BY THE TERMS OF THIS LICENSE. THE LICENSOR GRANTS YOU THE RIGHTS CONTAINED HERE IN CONSIDERATION OF YOUR ACCEPTANCE OF SUCH TERMS AND CONDITIONS