Why do older adults seek emergency care? The impact of contextual factors, care, health, and social relations

Background: Emergency department (ED) visits are becoming more prevalent globally. EDs provide care for acute health conditions, but some of these visits are driven by needs unmet by primary health care and social care for older adults, indicating ineffective social care and healthcare systems. The ED is often an inappropriate setting for older adults because of the lack of interdisciplinary teams with clinical competence in the care of an increasingly ageing population and because of poor continuity of care which entails the risk of adverse health outcomes. The Andersen model of health services use proposes contextual and individual factors to understand health care utilisation better. However, there are knowledge gaps in research on ED care in relation to contextual factors, home help receipt, and aspects related to inadequate informal care. Moreover, selection bias often limits previous research on ED care. Aim: The overall aim was to study factors associated with ED care use in older adults. Design: Prospective cohort study Study sample: All adults ≥65 years with ED visits in 2014 living in two Swedish regions (Dalarna, N=16 688 and Stockholm, N=101 017) participated in study I. The study population in study II was all community-living older-old adults (≥80 years) who were registered residents of Dalarna on 31 December 2014, excluding those who moved into residential care facilities during 2015 (N=16 543). In study III, the participants were adults ≥60 years who participated in the Swedish National Study on Aging and Care-Kungsholmen (SNAC-K). The data were pooled from three waves (W) of SNAC: W1= 2001-2003, W3=2007-2009, and W5=2013-2015. Persons living in residential care facilities were excluded from study III providing an analytical sample of N=3 066 at W1, N=1 885 at W3, and N=1 208 at W5. In study IV, adults ≥66 years who participated in the SNAC-Blekinge study (W3: 2007-2009) and who provided information on the exposure variable were included (N=673). Data sources: The four studies of this thesis were based on national and regional registers and survey data. The registers were the Longitudinal Integration Database for Health Insurance and Labour Market, the Social Services Register, the Swedish Prescribed Drug Register, the National Patient Register, and the health care databases of Region Blekinge, Dalarna, and Stockholm. Municipal-level data were accessed from Kolada, a publicly accessible, comprehensive national database. Survey data were based on the Swedish National study on Aging and Care in Blekinge and Kungsholmen. Dependent variables: The dependent variables were ED visits, at least one ED revisit within 30 days of an initial ED visit, and frequent ED use. Independent variables: The independent variables included contextual factors (the proportion of adults aged ≥80 years in the total population, annual social care expenditures per person aged ≥80 years, home help quality, median days in residential care, and distance to the ED), individual-level predisposing factors (age, gender, and education), individual-level enabling resources (living arrangements, social connections, social support, and informal care), individual-level need factors (subjective and objective health status), and health care and social care use (primary health care visits, specialist care visits, hospital admissions, ED visits in the previous year, disposition at initial ED visit (admission to inpatient care/discharged home), residential care receipt, and home help receipt). Data analyses: Logistic regression models were used to analyse the associations between independent variables and dichotomous dependent variables (ED visits, ED revisits, frequent ED use). Cox regression models were computed to determine the association between independent variables and time to the first ED visit. Associations between independent variables and the number of ED visits were assessed using generalised estimating equations with negative binomial regressions. In studies III and IV, all analyses were stratified by age group (Study III: younger-old, 80 years). Results: Analysis of contextual factors showed that the proportion of adults aged ≥80 years in the total population and shorter distance to the ED were associated with ED visits in older-old adults (Study II). There were mixed findings on age, gender, and education level for individual-level predisposing factors. Regarding individual-level enabling resources, higher levels of social support were negatively associated with ED visits but only in older-old adults (Study III). In relation to the need for care factors, poor health status was associated with ED visits (Studies II-IV), ED revisits (Study I), and frequent ED use (Study IV). Concerning the utilisation of care, primary health care visits in the previous 12 months were associated with ED visits (Study II) and ED revisits (Study I). Hospital admissions and ED visits 12 months before the initial ED visit were associated with ED revisits (Studies I & II). Older-old adults admitted to inpatient care at the initial ED visits were 29% less likely to revisit an ED within 30 days of the initial ED visit than those discharged home (Study II). Older-old adults receiving home help for instrumental services and personal care were 148% more likely to visit an ED compared to those not receiving home help. This group with intensive home help also had a 30% higher likelihood of an ED revisit within 30 days of the initial ED visit (Study II). Conclusions: Contextual factors contribute to understanding ED care use in older adults. Our findings on poor health status suggest that the need for care determines ED care use in older adults. However, factors other than health status also explain the use of ED care. For example, social support indicates inequalities and suggests investing in public health resources to address these risk factors. Discharge to home from the ED and risk of an ED revisit could indicate that health care and post-discharge care are not meeting the needs of older patients. Findings on the home help receipt and ED care use illustrate the vulnerability of this group and highlight the importance of future research on self-reported unmet needs of home help and the effect of unmet needs on the use of ED care

Utilization of RSM for optimization of physical variables to improve bacteriocin production from Lactobacillus plantarum strain MS

The utilization of natural antimicrobial substances has been increased in the pharmaceutical sector due to their stability and inhibition activity against pathogenic microorganisms. In the current study, the bacteriocin synthesis by locally isolated Lactobacillus plantarum MS from yogurt, has been optimized by using response surface methodology. Statistical optimization of physical variables by using Box-Behnken design, 3200 AU/mL bacteriocin activity was detected at 30 °C temperature, 18h incubation time and pH 6 against Staphylococcus aureus. The resulting bacteriocin was found to be stable a broad range of pH (2-12) and temperature (37-100 °C) but the activity of bacteriocin was slightly disturbed at 121 °C. Besides, bacteriocin showed stability after treatment with various enzymes (catalase, amylase, and lipase), salt (NaCl), and surfactants (triton X-100, EDTA, and SDS) but found sensitive by treating with proteolytic enzymes (proteinase K and trypsin) in comparison with untreated bacteriocin. Because of such biochemical characteristics, these antibacterial peptides could be possibly incorporated in the field of pharmacy to fulfil consumer’s demand for natural remedies

Ecological Applications of Enzymes in Plants Based Textile Dyeing

Biotechnology has a foremost role in the textile industry by enhancing ecofriendly, cost-effective, and energy-efficient manufacturing processes. The use of enzymatic biotechnology is one of the sustainable newly developed state-of-the-art processes for textile processing. To reduce the use of toxic and hazardous chemicals, enzymes have been proposed as one of the finest promising alternatives. Many enzymes have been used widely in textile processes such as lipase, laccase, pectinase, cellulase, catalase, amylase, and protease. The enzymatic use in the textile industry is very promising because they produce top-class goods, and give way to the reduction of water, time, and energy. The increasing demand for natural dyes especially with the incorporation of enzymes makes process more sustainable and eco-friendlier to suppress the toxicity of synthetic dyes. In the first part of the chapter, particular attention has been given to the source and extraction of natural dyes. In the second part of the chapter, different enzymes and their possible roles in the textile industry have been discussed. It is expected that this chapter will provide an innovative direction to the academic researchers, the community of textile and traders as well as artisans who are working in the area of biotechnological applications for the betterment of textile processing

A systematic review of longitudinal risk factors for loneliness in older adults

OBJECTIVES: To effectively reduce loneliness in older adults, interventions should be based on firm evidence regarding risk factors for loneliness in that population. This systematic review aimed to identify, appraise and synthesise longitudinal studies of risk factors for loneliness in older adults. METHODS: Searches were performed in June 2018 in PsycINFO, Scopus, Sociology Collection and Web of Science. Inclusion criteria were: population of older adults (M = 60+ years at outcome); longitudinal design; study conducted in an OECD country; article published in English in a peer-review journal. Article relevance and quality assessments were made by at least two independent reviewers. RESULTS: The search found 967 unique articles, of which 34 met relevance and quality criteria. The Netherlands and the United States together contributed 19 articles; 17 analysed national samples while 7 studies provided the data for 19 articles. One of two validated scales was used to measure loneliness in 24 articles, although 10 used a single item. A total of 120 unique risk factors for loneliness were examined. Risk factors with relatively consistent associations with loneliness were: not being married/partnered and partner loss; a limited social network; a low level of social activity; poor self-perceived health; and depression/depressed mood and an increase in depression. CONCLUSION: Despite the range of factors examined in the reviewed articles, strong evidence for a longitudinal association with loneliness was found for relatively few, while there were surprising omissions from the factors investigated. Future research should explore longitudinal risk factors for emotional and social loneliness

Individual and contextual predictors of emergency department visits among community-living older adults : a register-based prospective cohort study

OBJECTIVES: To examine the extent to which contextual factors explain emergency department (ED) visits and ED revisits, additional to that explained by individual factors. DESIGN: A register-based prospective cohort study. SETTING: Swedish region of Dalarna. PARTICIPANTS: Participants were 16 543 community-living adults aged 80 or older who were residents of the Dalarna region of Sweden, excluding older adults who moved out of Dalarna or into residential care during the study period. OUTCOME MEASURES: Dependent variables were initial ED visit, and at least one ED revisit within 30 days of an initial ED visit. RESULTS: Approximately 36% of the participants visited the ED during the study period with 18.9% returning to the ED within 30 days. For both initial ED visits and ED revisits, the addition of contextual factors to models containing individual factors significantly improved model fit (p<0.001; p<0.022) and the amount of variance explained in the outcome. In the final models, initial ED visit was significantly associated with older age, number of chronic diseases, receipt of home help, number of primary care visits, proportion of 80+ in the population and shorter distance to the ED; while an ED revisit was significantly associated with greater use of social care, number of hospital admissions and disposition (discharged; admitted to hospital) at initial ED visit. CONCLUSION: Contextual factors explain variance in initial ED visit, additional to that explained by individual factors alone, which indicates inequitable access to ED care. These findings suggest considering local variations in contextual factors in order to improve health-related outcomes among older adults

The role of social connections and support in the use of emergency care among older adults

Objectives: Limited and inconsistent findings have been reported on the link between social connections and support and emergency department (ED) visits in older populations. Moreover, the adequacy of informal care for older adults has rarely been considered. This study explored the associations of social connections, social support, and informal care with ED visits in younger-old (<78 years) and oldest-old (≥78 years) adults. Methods: This is a prospective cohort study based on community-living adults ≥60 years old participating in the Swedish National Study on Aging and Care in Kungsholmen (N=3066 at wave 1, 2001-2004; N=1885 at wave 3, 2007-2010; N=1208 at wave 5, 2013-2016). Standardised indexes were developed to measure social connections, social support, and informal care. The outcome variable was hospital-based ED visits within 4 years of the SNAC-K interview. Associations between exposure variables and ED visits were assessed through negative binomial regressions using generalised estimating equations. Results: Medium (IRR 0.77; 95% CI 0.59–0.99) and high (IRR 0.77; 95% CI 0.56–0.99) levels of social support were negatively associated with ED visits compared to low levels of social support, but only in oldest-old adults. No statistically significant associations were observed between social connections and ED visits. Higher ED visit rates were seen in oldest-old adults with unmet informal care needs, even if the differences did not reach statistical significance. Conclusions: ED visits were associated with social support levels among adults aged ≥78 years. Public health interventions to mitigate situations of poor social support may improve health outcomes and reduce avoidable ED visits in oldest-old adults. © 202

Ensamhet bland äldre personer i Norden

Rapporten presenterar översikter av tidigare forskning och analyser av känslan av ensamhet bland äldre personer. Överlag finns det kunskap om ensamhetens konsekvenser för ohälsa, men det behövs ytterligare forskning där starkare slutsatser kan dras om sambandens riktning, och ett tydligare fokus på ensamhet i gruppen äldre personer. En systematisk översikt visar att det finns god kunskap om en del faktorer som ökar risken för ensamhet, men mer forskning behövs om andra potentiella riskfaktorer. Analyserna visar en relativt låg och stabil förekomst av ensamhet bland äldre personer i Norden, samt att ohälsa och olika indikatorer för social exkludering (t.ex. bristande sociala relationer, otillräcklig inkomst, samt otrygghet i närområdet) har samband med ensamhet. Slutligen konstateras att forskningen om nordiska interventioner för att minska ensamhet bland äldre personer är begränsad

Factors associated with emergency department revisits among older adults in two Swedish regions : A prospective cohort study

Objectives To assess the association between baseline characteristics at an index ED visit and ED revisit within 30 days among adults aged ≥ 65 years in two Swedish regions. Methods This was a register-based prospective cohort study. The sample included (N=16 688; N=101 017) older adults who have had an index ED visit in 2014 at hospital based EDs in the regions of Dalarna and Stockholm, Sweden. Several registers were linked to obtain information on sociodemographic factors, living conditions, social care, polypharmacy and health care use. Multivariate logistic regression was used to analyse the data. Results Seventeen percent of the study sample in Dalarna and 20.1% in Stockholm revisited ED within 30 days after an index ED visit. In both regions, male gender, being in the last year of life, excessive polypharmacy (≥ 10 drugs), ≥11 primary care visits and ED care utilization were positively associated with ED revisits. In Stockholm, but not in Dalarna, low level of education, polypharmacy, and institutional care was also associated with ED revisits. In contrast, home help was associated with ED revisits in Dalarna but not in Stockholm. Conclusion These findings call for further in-depth examinations of variations within single countries. ED revisits among older adults are driven by need of care but also by the social and care situation

Comparison of diagnostic accuracy of magnetic resonance spectroscopy with conventional magnetic resonance imaging for brain tumors and correlation with histopathology as gold standard

Background; Despite a large number of revolutionized advancements in Imaging technology clinicians are unable to get hundred percent accurate results. Multiple limitations have been observed in Imaging modalities. Multiple published trials are available online on the evaluations of these imaging modalities individually and in combinations to find out the level of accuracy of these technologies. Objective; This study was design to compare the diagnostic accuracy of MR Spectroscopy with MRI which is a conventional diagnostic tool for brain tumor diagnosis while keeping the Histopathology evaluation as Gold Standard. Methodology; The patients who fulfilled the inclusion criteria were included in study. All scans were carried out on GE 1.5 Tesla MR Scanner using head coil. Axial T1W, T2W, Fluid Attenuated Inversion Recovery (FLAIR), Sagittal T2W, Coronal Fluid Attenuation. Inversion Recovery (FLAIR) and T1W post- contrast Axial, Coronal and Sagittal images were acquired. MR spectroscopy was performed through single voxel technique. Final diagnosis was made on histopathology results. The reports of biopsy were co related with radiological diagnosis of MRI and MRS. Results; The study was conducted with 150 suspected cases. There were 85(56.7%) males and 65(43.3%) females. Histopathology 100(66.7%) cases were confirmed positive and 50(33.3%) negative.&nbsp

Routine assessment of carotid plaques on Doppler USG and associated presenting symptoms at a Tertiary Care Centre, Lahore

Objective: To determine the frequency of carotid plaques on Doppler USG and associated presenting symptoms at Tertiary Care Centre, Lahore. Methods: A cross-sectional study of 366 individuals was conducted from January 2020 to November 2020 at the Radiology Department of Shiekh Zayed Hospital, Lahore, Pakistan. A consultant radiologist scanned both sides of the extra-cranial carotid artery tree. The DUS of carotid arteries was done with a GE Voluson Expert 730 Doppler ultrasound machine, using a linear probe with a transducer frequency of 6-12.5MHz. Results: A total of 366 patients underwent bilateral carotid Doppler ultrasound examinations. Our findings showed carotid plaques in 156 (42.62%) patients; the majority were males 105(67.53). The mean age recorded was 61.17 ±9.54 years and the mean body mass index was 25.43±3.40 Kg/m2. The highest number of plaques were noted in the left carotid artery 64 (41.03%), the main location was the common carotid artery 88 (56.41%) and, the majority were homogenous plagues 88 (56.41%).The majority of patients presented with headaches 177 (48.36%). Associated comorbidities were diabetes mellitus, hypertension, and dyslipidemia. Conclusion: The accuracy of diagnosing Carotid artery plaques has greatly increased over time payable to radiological innovation