What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review

Abstract Background Emergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address. Objectives To systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes. Design A systematic mapping review. Setting Evidence from developed countries on interventions delivered in the ED. Participants Frail and high-risk older people and general populations of older people (aged > 65 years). Interventions Interventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED. Main outcome measures Patient outcomes (direct and indirect) and health service outcomes. Data sources Evidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016. Review methods A review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made. Results Of the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes. Limitations This review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review. Conclusions A substantial body of evidence on interventions for frail and high-risk older people was identified and mapped. Future work Future work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients. Study registration This study is registered as PROSPERO CRD42016043260. Funding The National Institute for Health Research Health Services and Delivery Research programme

Horizontal Branch Stars: The Interplay between Observations and Theory, and Insights into the Formation of the Galaxy

We review HB stars in a broad astrophysical context, including both variable and non-variable stars. A reassessment of the Oosterhoff dichotomy is presented, which provides unprecedented detail regarding its origin and systematics. We show that the Oosterhoff dichotomy and the distribution of globular clusters (GCs) in the HB morphology-metallicity plane both exclude, with high statistical significance, the possibility that the Galactic halo may have formed from the accretion of dwarf galaxies resembling present-day Milky Way satellites such as Fornax, Sagittarius, and the LMC. A rediscussion of the second-parameter problem is presented. A technique is proposed to estimate the HB types of extragalactic GCs on the basis of integrated far-UV photometry. The relationship between the absolute V magnitude of the HB at the RR Lyrae level and metallicity, as obtained on the basis of trigonometric parallax measurements for the star RR Lyrae, is also revisited, giving a distance modulus to the LMC of (m-M)_0 = 18.44+/-0.11. RR Lyrae period change rates are studied. Finally, the conductive opacities used in evolutionary calculations of low-mass stars are investigated. [ABRIDGED]Comment: 56 pages, 22 figures. Invited review, to appear in Astrophysics and Space Scienc

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Efeito do fósforo suplementar sobre o desempenho reprodutivo de vacas de corte em pastagem de Brachiaria humidicola Effect of phosphorus supplementation on the reproductive performance of beef cows grazing Brachiaria humidicola

O objetivo deste experimento foi observar e quantificar o efeito de duas misturas minerais (ad libitum), uma sem (M) e outra com fósforo suplementar (MP), sobre o desempenho produtivo e reprodutivo de vacas de cria neloradas em pastejo de Brachiaria humidicola. O trabalho foi realizado na Fazenda Modelo (Embrapa-Centro Nacional de Pesquisa de Gado de Corte), localizada em Terenos, MS, em duas fases, a primeira, em 1988/92, e a segunda, em 1992/94. Na segunda fase, reduziu-se a carga animal durante a seca e os dias de amamentação (de 1,0 para 0,5 vacas/ha e de 210 para 90 dias, respectivamente). Foram realizadas medidas de consumo da mistura mineral (M = 76 e MP = 112 g/cab./dia); teor médio de fósforo na forrageira (época das chuvas = 0,16%, época seca = 0,11%); peso vivo (primeira fase: M = 363±3,3 e MP = 371±3,8 kg; segunda fase: M = 407± 5,7 e MP = 417± 6,5 kg); taxa de natalidade (primeira fase: M = 67±3,3 e MP = 66± 3,5%; segunda fase: M = 74± 6,3 e MP = 80± 5,7%) e bezerros desmamados (primeira fase: M = 86± 5,0 e MP = 91± 5,3; segunda fase: M = 55± 6,4 e MP = 67± 5,7). As vacas de cria não responderam ao fósforo suplementar.<br>The objective of this experiment was to observe and quantify the effect of two mineral mixtures, as free-choice feeding, one without (M) and other with phosphorus supplement (MP), on the productive and reproductive performance of Nellore beef cows grazing Brachiaria humidicola. This work was conducted at the Fazenda Modelo (Embrapa-Centro Nacional de Pesquisa de Gado de Corte), located in Terenos, MS, Brazil, in two phases, 1st from 1988/92 and 2nd from 1992/94. During the 2nd phase, stocking rate, for the dry period, and suckling days were reduced (from 1.0 to 0.5 cows/ha and 210 to 90 days, respectively). Mineral intake (M = 76 and MP = 112 g/had/day), forage phosphorus level (wet season = 0.16%; dry season = 0.11%), liveweight (1st phase: M = 363± 3.3 and MP = 371± 3.8 kg; 2nd phase: M = 407± 5.7 and MP = 417± 6.5 kg), birth percentage (1st phase: M = 67± 3.3 and MP = 66± 3.5; 2nd phase: M = 75± 6.3 and MP = 80± 5.7) and weaning of calves (1st phase: M = 86± 5.0 and MP = 91± 5.3; 2nd phase: M = 55± 6.4 and MP = 67&plusmn;5.7) were measured. Beef cattle is not responsive to P supplementation