The chaotic journey: recovering from hip fracture in a nursing home

Purpose of the study: To understand the journey experienced by nursing home residents following hip fracture and impressions of an outreach rehabilitation program offered after their return home.A qualitative investigation was undertaken in parallel with a randomised controlled trial investigating the efficacy and cost utility of providing a hospital outreach rehabilitation program for older nursing home residents who have recently returned from hospital following hip fracture. Family members and nursing home staff of 28 (out of the first 30) participants (14 from intervention and 14 from control) agreed to participate in interviews and focus groups to provide information and perceptions of each person's journey. NVivo 10 qualitative data analysis software package was used to identify major themes (via open, then axial and finally selective coding). Results: Both family members and staff described nursing home residents with dementia as receiving poor post-operative care from hospital staff who seemed unfamiliar with dementia and delirium. Discharge from hospital soon after surgery (median 4.5days) occurred with poor transfer of information. Difficulties with residents' emotions, pain management and commencing mobilisation seemed more prevalent within usual care group, whereas fewer overall problems were encountered by those with access to a geriatrician and additional therapy. Implications: This research suggests that an integrated care pathway including the hospital stay and first weeks back at nursing homes should be developed. Performance indicators should include carer measures on the quality of the transfer, pain management measures in the first month and return to walking.Maggie Killington, Ruth Walker, Maria Crott

Video and computer-based interactive exercises are safe and improve task-specific balance in geriatric and neurological rehabilitation: A randomised trial

© 2015. Question: Does adding video/computer-based interactive exercises to inpatient geriatric and neurological rehabilitation improve mobility outcomes? Is it feasible and safe? Design: Randomised trial. Participants: Fifty-eight rehabilitation inpatients. Intervention: Physiotherapist-prescribed, tailored, video/computer-based interactive exercises for 1 hour on weekdays, mainly involving stepping and weight-shifting exercises. Outcome measures: The primary outcome was the Short Physical Performance Battery (0 to 3) at 2 weeks. Secondary outcomes were: Maximal Balance Range (mm); Step Test (step count); Rivermead Mobility Index (0 to 15); activity levels; Activity Measure for Post Acute Care Basic Mobility (18 to 72) and Daily Activity (15 to 60); Falls Efficacy Scale (10 to 40), ED5D utility score (0 to 1); Reintegration to Normal Living Index (0 to 100); System Usability Scale (0 to 100) and Physical Activity Enjoyment Scale (0 to 126). Safety was determined from adverse events during intervention. Results: At 2 weeks the between-group difference in the primary outcome (0.1, 95% CI -0.2 to 0.3) was not statistically significant. The intervention group performed significantly better than usual care for Maximal Balance Range (38. mm difference after baseline adjustment, 95% CI 6 to 69). Other secondary outcomes were not statistically significant. Fifty-eight (55%) of the eligible patients agreed to participate, 25/29 (86%) completed the intervention and 10 (39%) attended > 70% of sessions, with a mean of 5.6 sessions (SD 3.3) attended and overall average duration of 4.5. hours (SD 3.1). Average scores were 62 (SD 21) for the System Usability Scale and 62 (SD 8) for the Physical Activity Enjoyment Scale. There were no adverse events. Conclusion: The addition of video/computer-based interactive exercises to usual rehabilitation is a safe and feasible way to increase exercise dose, but is not suitable for all. Adding the exercises to usual rehabilitation resulted in task-specific improvements in balance but not overall mobility. Registration: ACTRN12613000610730

Should we provide outreach rehabilitation to very old people living in Nursing Care Facilities after a hip fracture? A randomised controlled trial

Objective: to determine whether a 4-week postoperative rehabilitation program delivered in Nursing Care Facilities (NCFs) would improve quality of life and mobility compared with receiving usual care. Design: parallel randomised controlled trial with integrated health economic study. Setting: NCFs, in Adelaide South Australia. Subjects: people aged 70 years and older who were recovering from hip fracture surgery and were walking prior to hip fracture. Measurements: primary outcomes: mobility (Nursing Home Life-Space Diameter (NHLSD)) and quality of life (DEMQOL) at 4 weeks and 12 months. Results: participants were randomised to treatment (n = 121) or control (n = 119) groups. At 4 weeks, the treatment group had better mobility (NHLSD mean difference -1.9; 95% CI: -3.3, -0.57; P = 0.0055) and were more likely to be alive (log rank test P = 0.048) but there were no differences in quality of life. At 12 months, the treatment group had better quality of life (DEMQOL sum score mean difference = -7.4; 95% CI: -12.5 to -2.3; P = 0.0051), but there were no other differences between treatment and control groups. Quality adjusted life years (QALYs) gained over 12 months were 0.0063 higher per participant (95% CI: -0.0547 to 0.0686). The resulting incremental cost effectiveness ratios (ICERs) were $5,545 Australian dollars per unit increase in the NHLSD (95$244 to $15,159) and$328,685 per QALY gained (95% CI: $82,654 to$75,007,056). Conclusions: the benefits did not persist once the rehabilitation program ended but quality of life at 12 months in survivors was slightly higher. The case for funding outreach home rehabilitation in NCFs is weak from a traditional health economic perspective.Maria Crotty, Maggie Killington, Enwu Liu, Ian D. Cameron, Susan Kurrle, Billingsley Kaambwa, Owen Davies, Michelle Miller, Mellick Chehade, Julie Ratcliff

Mouse models of rhinovirus-induced disease and exacerbation of allergic airway inflammation

Rhinoviruses cause serious morbidity and mortality as the major etiological agents of asthma exacerbations and the common cold. A major obstacle to understanding disease pathogenesis and to the development of effective therapies has been the lack of a small-animal model for rhinovirus infection. Of the 100 known rhinovirus serotypes, 90% (the major group) use human intercellular adhesion molecule-1 (ICAM-1) as their cellular receptor and do not bind mouse ICAM-1; the remaining 10% (the minor group) use a member of the low-density lipoprotein receptor family and can bind the mouse counterpart. Here we describe three novel mouse models of rhinovirus infection: minor-group rhinovirus infection of BALB/c mice, major-group rhinovirus infection of transgenic BALB/c mice expressing a mouse-human ICAM-1 chimera and rhinovirus-induced exacerbation of allergic airway inflammation. These models have features similar to those observed in rhinovirus infection in humans, including augmentation of allergic airway inflammation, and will be useful in the development of future therapies for colds and asthma exacerbations

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Transcranial magnetic stimulation-electroencephalography measures of cortical neuroplasticity are altered after mild traumatic brain injury

While the potential long-term side effects of mild traumatic brain injury (mTBI) are becoming increasingly recognized, the associated neurophysiological mechanisms remain poorly understood. However, changes in cortical inhibitory function and neuroplasticity have been suggested as possible contributing factors. The current study applied transcranial magnetic stimulation (TMS) in conjunction with electroencephalography (combined TMS-EEG) to investigate further the effects of mTBI on these processes. In 17 patients with a history of mTBI and 15 healthy control subjects with no mTBI history, paired-pulse TMS-EEG measures of short- (SICI) and long-interval intracortical inhibition (LICI) were used to assess intracortical inhibitory function. Single-pulse TMS-EEG was used to assess neuroplastic changes in cortical excitability after application of continuous theta burst stimulation (cTBS, a plasticity inducing TMS paradigm). Inhibition of the TMS-evoked EEG potential after application of SICI and LICI was not different between groups. In contrast, the inhibitory effects of cTBS on both P30 (p < 0.05) and N45 (p = 0.04) TEP components was significantly increased in patients, with the modulation of N45 in patients significantly related to the time since injury (p = 0.04). While these results provide further evidence that inhibitory circuits involving γ-aminobutyric acid (GABA) are modified after mTBI, they place greater emphasis on the plasticity of inhibitory networks involving the GABA(A) receptor subtype.George M. Opie, Ngee Foo, Maggie Killington, Michael C. Ridding and John G. Semmle

Antigenic and protein sequence homology between VP13/14, a herpes simplex virus type 1 tegument protein, and gp10, a glycoprotein of equine herpesvirus 1 and 4.

Monospecific polyclonal antisera raised against VP13/14, a major tegument protein of herpes simplex virus type 1 cross-reacted with structural equine herpesvirus 1 and 4 proteins of Mr 120,000 and 123,000, respectively; these proteins are identical in molecular weight to the corresponding glycoprotein 10 (gp10) of each virus. Using a combination of immune precipitation and Western immunoblotting techniques, we confirmed that anti-VP13/14 and a monoclonal antibody to gp10 reacted with the same protein. Sequence analysis of a lambda gt11 insert of equine herpesvirus 1 gp10 identified an open reading frame in equine herpesvirus 4 with which it showed strong homology; this open reading frame also shared homology with gene UL47 of herpes simplex virus type 1 and gene 11 of varicella-zoster virus. This showed that, in addition to immunological cross-reactivity, VP13/14 and gp10 have protein sequence homology; it also allowed identification of VP13/14 as the gene product of UL47