Urban Governance as a Tool for Enhancing Resilient Urban Form: Case Study Alexandria, Egypt

Cities are continually changing in an adaptation process to overcome a diverse range of natural and man-made pressures. Natural disaster, political upheavals or economic crisis are examples of stresses that cities face and try to overcome in different ways by developing mechanisms for handling continues changes. Most of these stresses and pressures are interrelated, complicated and hard to predict in the future time. As a result of the wide range of shocks and stresses, cities may decay or collapse, affecting the lives of millions of people living within the urban areas. Therefore, to a certain extent, urban resilience is considered as one of the most essential topics within the discourses of the sustainable development as it tackles issues as risk reduction and disaster prevention. Accordingly, it was essential to develop and plan cities in ways that allow them to foster resilience to the uncertainty of the environmental, socio-economic and political changes overtime. Subsequently, the theory of resilience gained an attention within the urban field leading to the notion of urban resilience. In the last decades, Egypt as -a developing country- has witnessed several stresses due to major shifts in its political situation. Started at the 1950s with a shift from a monarchy to a socialist republic, followed by an open market system at the late 1970s, to reach a capitalist system in the early 1980s. All these major political shifts brought a wide range of urban governance forms, which in turn had significant effects on the urban form of the cities’ designed and built environment. In this context, urban governance changes in Egypt are frequent and consequent over a short period of time demonstrating the importance of tackling the issue of urban resilience. Designing and planning cities are profoundly political activities; therefore, politics should be prioritized in managing cities. Broadly, the research aims to explore the interplay between the urban governance and the resilience of the urban form over time. The research focuses on urban resilience in terms of long-term urban governance through studying the effect of the urban legislation of the different consequent systems on the city resilience. Accordingly, the research worked on developing a resilience index to measure the resilience of the urban form of a neighbourhood area in Alexandria through a time line while analysing the urban building laws that shaped this form. The study reaches a conclusion of identifying the legislation that formed the most resilient urban from over time

The Association Between the Body Mass Index and 4-Year All-Cause Mortality in Older Hospitalized Patients

Background. Association between body mass index (BMI) and long-term mortality is poorly studied in older hospitalized populations. Methods. The researchers prospectively studied the impact of the BMI, comorbidities, and malnutrition on long-term mortality in 444 patients (mean age 85.3±6.7 years; 74.0% women) receiving geriatric inpatient care. All-cause mortality was determined using simple and multiple Cox proportional hazard models. Results. Higher BMI was associated with a higher prevalence of diabetes, hypertension, and heart failure, but with a lower prevalence of malignancies. Four-year all-cause mortality was inversely associated with a BMI greater than or equal to 30kg/m2 (hazard ratio = 0.59, p = .037) and positively associated with age, male gender, several individual comorbidities, and the global disease load determined by the Cumulative Illness Rating scale. The inverse association between a BMI greater than or equal to 30 and mortality remained significant after adjustment for age, gender, smoking, individual comorbidities (including heart failure and malignancies), Cumulative Illness Rating scale scores, and malnutrition parameters (hazard ratio = 0.52, p = .015). One-year mortality was associated with the Cumulative Illness Rating scale score but not with BMI categories. There were no survival differences between patients in low (<20.0) and intermediate (20.0-24.9 and 25.0-29.9) BMI categories. Conclusions. A BMI greater than or equal to 30 is associated with better long-term survival in hospitalized older patients, even after extensive adjustment for comorbidities, malnutrition, and smoking. Conversely, a low BMI (<20-25) is not associated with excess mortality, likely due to the overriding impact of multiple comorbidities. The researchers' observations have important implications for the mortality risk stratification in older high-risk patient

End-of-Life Care of Persons With Dementia

Many clinicians with different training and practice are involved in the care of persons with dementia. Whereas neurologists and psychiatrists focus their attention on the early phase of dementia, geriatricians and palliative care specialists are particularly involved at the end of demented patients' lives. To summarize the progress of knowledge in this field, it seems possible to answer four fundamental questions. When? Several longitudinal studies of cohorts of demented and nondemented patients showed clearly that dementia is a risk factor for early death. There are no survival differences between Alzheimer's and Lewy body disease patients. Patients with vascular dementia have the worst prognosis. These results need to be analyzed with consideration of associated comorbidity, types and intensity of care, and dementia treatment. Why? Studies conducted on the basis of death certificates appear to be biased. A large autopsy study performed in the geriatric department of Geneva University Hospital showed no difference existed in immediate causes of death between demented and nondemented hospitalized old patients. On the other hand, cardiac causes are significantly more frequent in vascular dementia than in Alzheimer's disease or mixed dementia patients. How? Deaths of demented patients raise a lot of ethical considerations. It is always difficult to know demented patients' awareness of the end of life. It is really difficult to accompany these patients, with whom communication is essentially nonverbal. During this delicate phase of the end of life, how can formal health professionals help the family members who are afraid of both death and dementia? And after? Suffering of family members and caregivers has to be strongly considered. This goal includes the improvement of our communication skills with the patient, and the facilitation of interdisciplinary exchanges with the caregiver's team and with the family members to allow acceptance of the deat

Efficiency and applicability of comprehensive geriatric assessment in the Emergency Department: a systematic review

Background and aims: Comprehensive geriatric assessment (CGA) may benefit frail or chronically ill patients in the emergency department (ED), but take too much time to be performed routinely in ED. An alternative approach is to use first a screening tool to detect high-risk patients and then perform CGA in these patients only. This systematic review focuses on the use and value of CGA in ED for evaluation of older patients and its influence on adverse outcomes. This approach is compared with an alternative one using existing screening tools, validated in ED, to detect high-risk patients needing subsequent CGA. This review ends by suggesting a short assessment of CGA to be used in ED and ways to improve home discharge management from ED. Methods: A systematic English Medline literature search was conducted in December 2009, with no date limit with the following Medical Subject Heading (MeSH) terms: "Frail Elderly”, "Health Services for Aged”, "Community Health Nursing”, "Emergency Service, Hospital”, "Geriatric Assessment”, "Patient Discharge”, "Risk Assessment” and "Triage”. Results: We selected 8 studies on CGA efficiency and 14 on screening tools. CGA in ED is efficient for decreasing functional decline, ED readmission and possibly nursing home admission in high-risk patients. As CGA takes too much time to be performed routinely in ED, validated screening tools can be applied to detect high-risk patients who will benefit most from CGA. Conclusions: The selected studies demonstrated that screening of high-risk patients is more efficient than age-based screening, and that CGA performed in ED, followed by appropriate interventions, improves outcome

Mild cognitive impairment, degenerative and vascular dementia as predictors of intra-hospital, short- and long-term mortality in the oldest old

Background and aims: The relative weight of various etiologies of dementia and mild cognitive impairment (MCI) as predictors of intra-hospital, short- and long-term mortality in very old acutely ill patients suffering from multiple comorbid conditions remains unclear. We investigated intra-hospital, 1- and 5-year mortality risk associated with dementia and its various etiologies in a very old population after discharge from acute care. Methods: Prospective cohort study of 444 patients (mean age 85 years; 74% female) discharged from the acute geriatric unit of Geneva University Hospital. On admission, each subject underwent standardized evaluation of cognitive and comorbid conditions. Patients were followed yearly by the same team. Predictive variables were age, sex, cognitive diagnosis, dementia etiology and severity. Survival during hospitalization, at 1- and 5-year follow-ups was the outcome of interest evaluated with Cox proportional hazard models. Results: Two hundred and six patients were cognitively normal, 48 had MCI, and 190 had dementia: of these, there were 75 cases of Alzheimer's disease (AD), 20 of vascular dementia (VaD), 82 of mixed dementia (MD) and 13 of other types of dementia. The groups compared were statistically similar in age, sex, education level and comorbidity score. After 5 years of follow-up, 60% of the patients had died. Regarding intra-hospital mortality, none of the predictive variables was associated with mortality. MCI, AD and MD were not predictive of short- or long-term mortality. Features significantly associated with reduced survival at 1 and 5 years were being older, male, and having vascular or severe dementia. When all the variables were added in the multiple model, the dementia effect completely disappeared. Conclusions: Dementia (all etiologies) is not predictive of mortality. The observed VaD effect is probably linked to cardiovascular risk comorbidities: hypertension, stroke and hyperlipidemi

Demented versus non-demented very old inpatients: the same comorbidities but poorer functional and nutritional status

Background: demented patients have been reported to be healthier than other old people of the same age. Objectives: to assess comorbid conditions, functional and nutritional status in medically ill hospitalised patients with normal cognition or affected by dementia of various causes and severities, or mild cognitive impairment (MCI). Design and Setting: a prospective study was carried out, between January and December 2004, in the Rehabilitation and Geriatric Hospital (HOGER). Methods: activities of daily living (ADL), instrumental activities of daily living (IADL) and mini nutritional assessment (MNA) scores were assessed as a function of the status of the patient two weeks before admission to hospital. On admission, cognitive status was assessed by a systematic battery of neuropsychological tests, comorbid conditions were assessed with the Charlson comorbidity index (CCI), and body mass index (BMI) and functional independence measure (FIM) were determined. BMI and FIM were also determined on discharge. Results: we studied 349 patients (mean age 85.2±6.7; 76% women): 161 (46.1%) cognitively normal, 37 (10.6%) with MCI and 151 (43.3%) demented (61 Alzheimer's disease (AD), 62 mixed dementia (MD) and 17 vascular dementia (VaD)). ADL, IADL, FIM and MNA scores on admission decreased with cognitive status, regardless of the type of dementia. Functionality at discharge remained significantly lower in demented patients than in other patients. CCI was high and similar in all three groups (mean 4.6±2.7). Patients with VaD had poorer health than other demented patients, with a higher average comorbidity score, more frequent hypertension, stroke and hyperlipidaemia. Comorbidity did not increase with severity levels of dementia. Conclusions: in this cohort of very old inpatients, demented patients, non-demented patients and patients with MCI had similar levels of comorbidity, but demented patients had a poorer functional and nutritional statu

A novel prosthesis presentation test to screen for cognitive and functional decline

Objectives and background To validate a novel screening test for cognitive and functional decline in older patients rehabilitated with complete removable dental prostheses (CRDPs). Materials and methods Edentate old in‐patients rehabilitated with CRDPs were included in this study. Participants were requested to remove their prostheses before their intraoral examinations. The prostheses were then presented in an inverted orientation. Participants had to correct the orientation of the prostheses and insert them in the appropriate jaws. The test was repeated after the intraoral exam. Appropriate statistical models were used (⍺ = .05) to associate the test results with the participants' mini‐mental state examination (MMSE) score, functional independence measure (FIM), age and sex. Results Among the 86 participants (mean‐age: 85.4 ± 6.4 years; mean MMSE: 19.8 ± 5.5; mean FIM: 77.9 ± 20.8), 21 (24.4%) failed to correctly insert the prosthesis. The prosthesis presentation test (PPT) was associated with the FIM but not the MMSE. Regression models further confirmed an association with age (P = .043), but not sex. Additional analyses revealed the PPT test is associated with the FIM's cognitive sub‐sets of memory, problem solving and social interaction. Conclusion The PPT is a novel, simple and quick screening tool that can help detect functional difficulties in older people. It can easily be performed during an oral examination. Future studies are needed to determine whether the PPT can be used to detect deficits in executive function, as a complement to the MMSE and also as a first assessment of a patient's ability to manage dentures independently

Telomere length, comorbidity, functional, nutritional and cognitive status as predictors of 5 years post hospital discharge survival in the oldest old

Background: Telomere length has been considered in many cross-sectional studies as a biomarker of aging. However the association between shorter telomeres with lower survival at advanced ages remains a controversial issue. This association could reflect the impact of other health conditions than a direct biological effect. Objective: To test whether leukocyte telomere length is associated with 5-year survival beyond the impact of other risk factors of mortality like comorbidity, functional, nutritional and cognitive status. Design: Prospective study. Setting and participants: A population representative sample of 444 patients (mean age 85 years; 74% female) discharged from the acute geriatric hospital of Geneva University Hospitals (January-December 2004), since then 263 (59.2%) had died (December 2009). Measurements: Telomere length in leukocytes by flow cytometry. Results: In univariate model, telomere length at baseline and cognitive status were not significantly associated with mortality even when adjusting for age (R2=9.5%) and gender (R2=1.9%). The best prognostic predictor was the geriatric index of comorbidity (GIC) (R2=8.8%; HR=3.85) followed by more dependence in instrumental (R2=5.9%; HR=3.85) and based (R2=2.3%; HR=0.84) activities of daily living and lower albumin levels (R2=1.5%; HR=0.97). Obesity (BMI>30: R2=1.6%; HR=0.55) was significantly associated with a two-fold decrease in the risk of mortality compared to BMI between 20-25. When all independent variables were entered in a full multiple Cox regression model (R2=21.4%), the GIC was the strongest risk predictor followed by the nutritional and functional variables. Conclusion: Neither telomeres length nor the presence of dementia are predictors of survival whereas the weight of multiple comorbidity conditions, nutritional and functional impairment are significantly associated with 5-year mortality in the oldest ol

The pandemic toll and post-acute sequelae of SARS-CoV-2 in healthcare workers at a Swiss University Hospital.

Healthcare workers have potentially been among the most exposed to SARS-CoV-2 infection as well as the deleterious toll of the pandemic. This study has the objective to differentiate the pandemic toll from post-acute sequelae of SARS-CoV-2 infection in healthcare workers compared to the general population. The study was conducted between April and July 2021 at the Geneva University Hospitals, Switzerland. Eligible participants were all tested staff, and outpatient individuals tested for SARS-CoV-2 at the same hospital. The primary outcome was the prevalence of symptoms in healthcare workers compared to the general population, with measures of COVID-related symptoms and functional impairment, using prevalence estimates and multivariable logistic regression models. Healthcare workers (n=3,083) suffered mostly from fatigue (25.5%), headache (10.0%), difficulty concentrating (7.9%), exhaustion/burnout (7.1%), insomnia (6.2%), myalgia (6.7%) and arthralgia (6.3%). Regardless of SARS-CoV-2 infection, all symptoms were significantly higher in healthcare workers than the general population (n=3,556). SARS-CoV-2 infection in healthcare workers was associated with loss or change in smell, loss or change in taste, palpitations, dyspnea, difficulty concentrating, fatigue, and headache. Functional impairment was more significant in healthcare workers compared to the general population (aOR 2.28; 1.76-2.96), with a positive association with SARS-CoV-2 infection (aOR 3.81; 2.59-5.60). Symptoms and functional impairment in healthcare workers were increased compared to the general population, and potentially related to the pandemic toll as well as post-acute sequelae of SARS-CoV-2 infection. These findings are of concern, considering the essential role of healthcare workers in caring for all patients including and beyond COVID-19

P3‐209: Impact of Biomarkers On Diagnostic Confidence in Clinical Assessment of Patients with Suspected Alzheimer's Disease and High Diagnostic Uncertainty: An EADC Study

Background: NIA-AA and IWG diagnostic criteria for Alzheimer's Disease (AD) include core structural, functional, and CSF biomarkers. The impact of core biomarkers in clinical settings is still unclear. This study aimed at measuring the impact of core biomarkers on the diagnostic confidence of uncertain AD cases in a routine memory clinic setting. // Methods: 356 patients with mild dementia (MMSE = 20) or Mild Cognitive Impairment possibly due to AD were recruited in 17 European Alzheimer's Disease Consortium (EADC) memory clinics. The following variables were collected: age; sex; MMSE; neuropsychological evaluation including long term memory, executive functions, language and visuospatial abilities. Core biomarkers were collected following local practices: Scheltens’s visual assessment of medial temporal atrophy (MTA) on MR scan; visual assessment of hypometabolism/hypoperfusion on FDG-PET/SPECT brain scan; CSF Aß1-42, tau and phospho-tau levels. At diagnostic workup completion, an estimate of confidence that cognitive complaints were due to AD was elicited from clinicians on a structured scale ranging from 0 to 100. Only cases with uncertain diagnoses (confidence between 15% and 85%) were retained for analysis. Generalized linear models were used to describe the relationship between the collected measures and the diagnostic confidence of AD. // Results: Neuropsychological assessment was carried out in almost all cases (98% of the cases). Medial temporal atrophy ratings were done in 40% of cases, assessment of cortical hypometabolism/hypoperfusion in 34%, and CSF Aß and tau levels in 26%. The markers that better explained the variability of diagnostic confidence were CSF Aß1-42 level (R2=0.46) and hypometabolism/hypoperfusion (R2=0.45), followed by CSF tau level (R2=0.35), MTA assessment (R2=0.32) and. All figures were highly significant, at p<<0.001. The diagnostic confidence variability due to neuropsychological tests for different domains was lower: MMSE (R2=0.29); long term memory (R2=0.23); executive functions (R2=0.05); language (R2=0.02); visuospatial abilities (R2=0.04) even if significant (p<0.01). // Conclusions: The use of core biomarkers in the clinical assessment of subjects with suspected AD and high diagnostic uncertainty is still limited. However, when assessed, these biomarkers show a higher impact on diagnostic confidence of AD than the most widespread clinical measures