The association between cognitive impairment and functional outcome in hospitalised older patients: a systematic review and meta-analysis

BACKGROUND: in hospitalised older adults, cognitive impairments are common and may be associated with functional outcomes. Our aim was to systematically review this association. METHOD: we systematically searched MEDLINE, CINAHL, AMED and PsycINFO from inception to April 2016. Non-English language studies were filtered out at search stage. All types of studies were considered for inclusion except reviews, conference abstracts, dissertations and case studies. Population: community-dwelling or institutionalised older adults aged 65 years or more, who are acutely hospitalised and have information on history of dementia and/or cognitive scores on admission. Setting: acute hospital (excluding critical care and subacute or intermediate care). Outcome of interest: change in a measure of physical function or disability between pre-admission or admission, and discharge or post-discharge. This review was registered on PROSPERO (CRD42016035978). RESULTS: the search returned 5,988 unique articles, of which 34 met inclusion criteria. All studies were observational, with 30 prospective and 4 retrospective from 14 countries, recruiting from general medicine (n = 11), geriatric medicine (n = 11) and mixed (n = 12) wards. Twenty-six studies (54,637 participants) were suitable for the quantitative synthesis. The meta-analysis suggested that cognitive impairment was associated with functional decline in hospitalised older adults (risk ratio (RR): 1.64; 95% confidence interval (CI): 1.45–1.86; P < 0.01). Results were similar in subanalyses focusing on diagnosis of dementia (RR: 1.36; 95% CI: 1.05–1.76; P = 0.02; n= 2,248) or delirium (RR: 1.55; 95% CI: 1.31–1.83; P < 0.01; n= 1,677). CONCLUSION: cognitive impairments seem associated with functional decline in hospitalised older people. Causality cannot be inferred, and limitations include low quality of studies and possible confounding

Thromboelastography results on citrated whole blood from clinically healthy cats depend on modes of activation

<p>Abstract</p> <p>Background</p> <p>During the last decade, thromboelastography (TEG) has gained increasing acceptance as a diagnostic test in veterinary medicine for evaluation of haemostasis in dogs, however the use of TEG in cats has to date only been described in one previous study and a few abstracts. The objective of the present study was to evaluate and compare three different TEG assays in healthy cats, in order to establish which assay may be best suited for TEG analyses in cats.</p> <p>Methods</p> <p>90 TEG analyses were performed on citrated whole blood samples from 15 clinically healthy cats using assays without activator (native) or with human recombinant tissue factor (TF) or kaolin as activators. Results for reaction time (R), clotting time (K), angle (α), maximum amplitude (MA) and clot lysis (LY30; LY60) were recorded.</p> <p>Results</p> <p>Coefficients of variation (CVs) were highest in the native assay and comparable in TF and kaolin activated assays. Significant differences were observed between native and kaolin assays for all measured parameters, between kaolin and TF for all measured parameters except LY60 and between native and TF assays for R and K.</p> <p>Conclusion</p> <p>The results indicate that TEG is a reproducible method for evaluation of haemostasis in clinically healthy cats. However, the three assays cannot be used interchangeably and the kaolin- and TF activated assays have the lowest analytical variation indicating that using an activator may be superior for performing TEG in cats.</p

Variation in Structure and Process of Care in Traumatic Brain Injury: Provider Profiles of European Neurotrauma Centers Participating in the CENTER-TBI Study.

INTRODUCTION: The strength of evidence underpinning care and treatment recommendations in traumatic brain injury (TBI) is low. Comparative effectiveness research (CER) has been proposed as a framework to provide evidence for optimal care for TBI patients. The first step in CER is to map the existing variation. The aim of current study is to quantify variation in general structural and process characteristics among centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. METHODS: We designed a set of 11 provider profiling questionnaires with 321 questions about various aspects of TBI care, chosen based on literature and expert opinion. After pilot testing, questionnaires were disseminated to 71 centers from 20 countries participating in the CENTER-TBI study. Reliability of questionnaires was estimated by calculating a concordance rate among 5% duplicate questions. RESULTS: All 71 centers completed the questionnaires. Median concordance rate among duplicate questions was 0.85. The majority of centers were academic hospitals (n = 65, 92%), designated as a level I trauma center (n = 48, 68%) and situated in an urban location (n = 70, 99%). The availability of facilities for neuro-trauma care varied across centers; e.g. 40 (57%) had a dedicated neuro-intensive care unit (ICU), 36 (51%) had an in-hospital rehabilitation unit and the organization of the ICU was closed in 64% (n = 45) of the centers. In addition, we found wide variation in processes of care, such as the ICU admission policy and intracranial pressure monitoring policy among centers. CONCLUSION: Even among high-volume, specialized neurotrauma centers there is substantial variation in structures and processes of TBI care. This variation provides an opportunity to study effectiveness of specific aspects of TBI care and to identify best practices with CER approaches

Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: A survey in 66 neurotrauma centers participating in the CENTER-TBI study

The distributions of species are not only determined by where they can survive – they must also be able to reproduce. Although immigrant inviability is a well-established concept, the fact that immigrants also need to be able to effectively reproduce in foreign environments has not been fully appreciated in the study of adaptive divergence and speciation. Fertilization and reproduction are sensitive life-history stages that could be detrimentally affected for immigrants in non-native habitats. We propose that “immigrant reproductive dysfunction” is a hitherto overlooked aspect of reproductive isolation caused by natural selection on immigrants. This idea is supported by results from experiments on an externally fertilizing fish (sand goby, Pomatoschistus minutus). Growth and condition of adults were not affected by non-native salinity whereas males spawning as immigrants had lower sperm motility and hatching success than residents. We interpret these results as evidence for local adaptation or acclimation of sperm, and possibly also components of paternal care. The resulting loss in fitness, which we call “immigrant reproductive dysfunction,” has the potential to reduce gene flow between populations with locally adapted reproduction, and it may play a role in species distributions and speciation.</p

Variation in structure and process of care in traumatic brain injury: Provider profiles of European Neurotrauma Centers participating in the CENTER-TBI study

Introduction: The strength of evidence underpinning care and treatment recommendations in traumatic brain injury (TBI) is low. Comparative effectiveness research (CER) has been proposed as a framework to provide evidence for optimal care for TBI patients. The first step in CER is to map the existing variation. The aim of current study is to quantify variation in general structural and process characteristics among centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Methods: We designed a set of 11 provider profiling questionnaires with 321 questions about various aspects of TBI care, chosen based on literature and expert opinion. After pilot testing, questionnaires were disseminated to 71 centers from 20 countries participating in the CENTER-TBI study. Reliability of questionnaires was estimated by calculating a concordance rate among 5% duplicate questions.Results: All 71 centers completed the questionnaires. Median concordance rate among duplicate questions was 0.85. The majority of centers were academic hospitals (n = 65, 92%), designated as a level I trauma center (n = 48, 68%) and situated in an urban location (n = 70, 99%). The availability of facilities for neuro-trauma care varied across centers; e.g. 40 (57%) had a dedicated neuro-intensive care unit (ICU), 36 (51%) had an in-hospital rehabilitation unit and the organization of the ICU was closed in 64% (n = 45) of the centers. In addition, we found wide variation in processes of care, such as the ICU admission policy and intracranial pressure monitoring policy among centers. Conclusion: Even among high-volume, specialized neurotrauma centers there is substantial variation in structures and processes of TBI care. This variation provides an opportunity to study effectiveness of specific aspects of TBI care and to identify best practices with CER approaches.</p

Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: A survey in 66 neurotrauma centers participating in the CENTER-TBI

Background: No definitive evidence exists on how intracranial hypertension should be treated in patients with traumatic brain injury (TBI). It is therefore likely that centers and practitioners individually balance potential benefits and risks of different intracranial pressure (ICP) management strategies, resulting in practice variation. The aim of this study was to examine variation in monitoring and treatment policies for intracranial hypertension in patients with TBI. Methods: A 29-item survey on ICP monitoring and treatment was developed based on literature and expert opinion, and pilot-tested in 16 centers. The questionnaire was sent to 68 neurotrauma centers participating in the Collaborative European Neurotrauma Effectiveness Research (CENTER-TBI) study. Results: The survey was completed by 66 centers (97% response rate). Centers were mainly academic hospitals (n = 60, 91%) and designated level I trauma centers (n = 44, 67%). The Brain Trauma Foundation guidelines were used in 49 (74%) centers. Approximately ninety percent of the participants (n = 58) indicated placing an ICP monitor in patients with severe TBI and computed tomography abnormalities. There was no consensus on other indications or on peri-insertion precautions. We found wide variation in the use of first- and second-tier treatments for elevated ICP. Approximately half of the centers were classified as having a relatively aggressive approach to ICP monitoring and treatment (n = 32, 48%), whereas the others were considered more conservative (n = 34, 52%). Conclusions: Substantial variation was found regarding monitoring and treatment policies in patients with traumatic brain injury and intracranial hypertension. The results of this survey indicate a lack of consensus between European neurotrauma centers and provide an opportunity and necessity for comparative effectiveness research