Quality and safety of acute hospital care for older patients:Patient safety, patient-centeredness and timeliness

The World Health Organization defines quality of care as: “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes, based on evidence-based professional knowledge”. There has been widespread international attention for quality of care. Despite the importance and efforts already made, ensuring high standards of care delivery can be challenging for healthcare professionals and –organizations. This thesis aims to contribute to the understanding of quality of acute hospital care for older patients, focused on patient safety, patient-centeredness and timeliness of care. We aimed to answer the following research questions: I.How safe is acute hospital care for older patients over time and currently? II.How patient-centered is acute hospital care for older patients? III.How timely is acute hospital care for older patients? In part I of this thesis multiple studies are described on the topic of patient safety. Chapter 2 shows that the incidence of AEs in older acutely admitted patients declined over the years (2008-2016). However, the preventability increased again after an initial decline. In chapter 3 we found a high prevalence of (fatal) AEs in older patients undergoing total hip arthroplasty or hemi-arthroplasty for a femoral neck fracture. This seemed particularly valid for cemented implants in highly frail old patients. In chapter 4 we found that AE risks appeared to be equally prevalent in patients with- and patients without a condition relevant for palliative care. But, the nature of AEs did differ between groups: medication- versus surgery-related. Based on the results of these studies, our answer to research question 1 is that although improvements have been made over the years, there is still room for improvement in patient safety for older patients. In part II we described multiple studies on the topic of patient-centeredness. In chapter 5 we found that “what matters most” to acutely admitted patients was mostly disease- and care-oriented. However, “why this matters most” topics were diverse, more personal, and often related to psychological well-being and relations. More than half of the included patients felt their treating doctor did not know what mattered most to them. Chapter 6 provides insight in the experiences and perspectives of older patients who visit the emergency department with a return visit within 30 days. The two major findings were that lack of clarity regarding waiting times and suboptimal discharge communication contributed to negative experiences. Chapter 7 shows that that few information about symptoms at the end of life is found in EHRs of deceased hospital patients. Symptoms are rarely measured with standardized methods in patients who died in Dutch Hospitals. In answer to our second research question, we conclude that when it comes to the elements of patients-centeredness that we measured (patient experiences and perspectives, what matters most, and quality indicators on physical/emotional comfort) there is also room for improvement. In part III we described two studies on the topic timeliness. In chapter 8 we found that in the Netherlands there is a slight increase in the absolute number of older patients that visit the ED, and the total number of ED visits by older patients. However, this rise is consistent with overall population growth of older people. Chapter 9 shows that approximately one in five admitted patients occupying hospital beds did not meet the criteria for acute in-hospital stay or care. In other words: inappropriate bed occupancy. Most discharge delays were related to issues outside the immediate control of the hospital. In answer to our third research question we conclude that acute care for older patients might not always be timel

Can vital signs recorded in patients' homes aid decision making in emergency care? A Scoping Review

Aim: Use of tele-health programs and wearable sensors that allow patients to monitor their own vital signs have been expanded in response to COVID-19. We aimed to explore the utility of patient-held data during presentation as medical emergencies. Methods: We undertook a systematic scoping review of two groups of studies: studies using non-invasive vital sign monitoring in patients with chronic diseases aimed at preventing unscheduled reviews in primary care, hospitalization or emergency department visits and studies using vital sign measurements from wearable sensors for decision making by clinicians on presentation of these patients as emergencies. Only studies that described a comparator or control group were included. Studies limited to inpatient use of devices were excluded. Results: The initial search resulted in 896 references for screening, nine more studies were identified through searches of references. 26 studies fulfilled inclusion and exclusion criteria and were further analyzed. The majority of studies were from telehealth programs of patients with congestive heart failure or Chronic Obstructive Pulmonary Disease. There was limited evidence that patient held data is currently used to risk-stratify the admission or discharge process for medical emergencies. Studies that showed impact on mortality or hospital admission rates measured vital signs at least daily. We identified no interventional study using commercially available sensors in watches or smart phones. Conclusions: Further research is needed to determine utility of patient held monitoring devices to guide management of acute medical emergencies at the patients’ home, on presentation to hospital and after discharge back to the community

Baicalin Improves Survival in a Murine Model of Polymicrobial Sepsis via Suppressing Inflammatory Response and Lymphocyte Apoptosis

BACKGROUND: An imbalance between overwhelming inflammation and lymphocyte apoptosis is the main cause of high mortality in patients with sepsis. Baicalin, the main active ingredient of the Scutellaria root, exerts anti-inflammatory, anti-apoptotic, and even antibacterial properties in inflammatory and infectious diseases. However, the therapeutic effect of baicalin on polymicrobial sepsis remains unknown. METHODOLOGY/PRINCIPAL FINDINGS: Polymicrobial sepsis was induced by cecal ligation and puncture (CLP) in C57BL/6 mice. Mice were infused with baicalin intraperitoneally at 1 h, 6 h and 12 h after CLP. Survival rates were assessed over the subsequent 8 days. Bacterial burdens in blood and peritoneal cavity were calculated to assess the bacterial clearance. Neutrophil count in peritoneal lavage fluid was also calculated. Injuries to the lung and liver were detected by hematoxylin and eosin staining. Levels of cytokines, including tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-10 and IL-17, in blood and peritoneum were measured by enzyme-linked immunosorbent assay. Adaptive immune function was assessed by apoptosis of lymphocytes in the thymus and counts of different cell types in the spleen. Baicalin significantly enhanced bacterial clearance and improved survival of septic mice. The number of neutrophils in peritoneal lavage fluid was reduced by baicalin. Less neutrophil infiltration of the lung and liver in baicalin-treated mice was associated with attenuated injuries to these organs. Baicalin significantly reduced the levels of proinflammatory cytokines but increased the level of anti-inflammatory cytokine in blood and peritoneum. Apoptosis of CD3(+) T cell was inhibited in the thymus. The numbers of CD4(+), CD8(+) T lymphocytes and dendritic cells (DCs) were higher, while the number of CD4(+)CD25(+) regulatory T cells was lower in the baicalin group compared with the CLP group. CONCLUSIONS/SIGNIFICANCE: Baicalin improves survival of mice with polymicrobial sepsis, and this may be attributed to its antibacterial property as well as its anti-inflammatory and anti-apoptotic effects

Clinical and molecular characterization of a cohort of patients with novel nucleotide alterations of the Dystrophin gene detected by direct sequencing

<p>Abstract</p> <p>Background</p> <p>Duchenne and Becker Muscular dystrophies (DMD/BMD) are allelic disorders caused by mutations in the dystrophin gene, which encodes a sarcolemmal protein responsible for muscle integrity. Deletions and duplications account for approximately 75% of mutations in DMD and 85% in BMD. The implementation of techniques allowing complete gene sequencing has focused attention on small point mutations and other mechanisms underlying complex rearrangements.</p> <p>Methods</p> <p>We selected 47 patients (41 families; 35 DMD, 6 BMD) without deletions and duplications in <it>DMD </it>gene (excluded by multiplex ligation-dependent probe amplification and multiplex polymerase chain reaction analysis). This cohort was investigated by systematic direct sequence analysis to study sequence variation. We focused our attention on rare mutational events which were further studied through transcript analysis.</p> <p>Results</p> <p>We identified 40 different nucleotide alterations in DMD gene and their clinical correlates; altogether, 16 mutations were novel. DMD probands carried 9 microinsertions/microdeletions, 19 nonsense mutations, and 7 splice-site mutations. BMD patients carried 2 nonsense mutations, 2 splice-site mutations, 1 missense substitution, and 1 single base insertion. The most frequent stop codon was TGA (n = 10 patients), followed by TAG (n = 7) and TAA (n = 4). We also analyzed the molecular mechanisms of five rare mutational events. They are two frame-shifting mutations in the <it>DMD </it>gene 3'end in BMD and three novel splicing defects: IVS42: c.6118-3C>A, which causes a leaky splice-site; c.9560A>G, which determines a cryptic splice-site activation and c.9564-426 T>G, which creates pseudoexon retention within IVS65.</p> <p>Conclusion</p> <p>The analysis of our patients' sample, carrying point mutations or complex rearrangements in <it>DMD </it>gene, contributes to the knowledge on phenotypic correlations in dystrophinopatic patients and can provide a better understanding of pre-mRNA maturation defects and dystrophin functional domains. These data can have a prognostic relevance and can be useful in directing new therapeutic approaches, which rely on a precise definition of the genetic defects as well as their molecular consequences.</p

Rapid Analysis of Saccharomyces cerevisiae Genome Rearrangements by Multiplex Ligation–Dependent Probe Amplification

Aneuploidy and gross chromosomal rearrangements (GCRs) can lead to genetic diseases and the development of cancer. We previously demonstrated that introduction of the repetitive retrotransposon Ty912 onto a nonessential chromosome arm of Saccharomyces cerevisiae led to increased genome instability predominantly due to increased rates of formation of monocentric nonreciprocal translocations. In this study, we adapted Multiplex Ligation–dependent Probe Amplification (MLPA) to analyze a large numbers of these GCRs. Using MLPA, we found that the distribution of translocations induced by the presence of Ty912 in a wild-type strain was nonrandom and that the majority of these translocations were mediated by only six translocation targets on four different chromosomes, even though there were 254 potential Ty-related translocation targets in the S. cerevisiae genome. While the majority of Ty912-mediated translocations resulted from RAD52-dependent recombination, we observed a number of nonreciprocal translocations mediated by RAD52-independent recombination between Ty1 elements. The formation of these RAD52-independent translocations did not require the Rad51 or Rad59 homologous pairing proteins or the Rad1–Rad10 endonuclease complex that processes branched DNAs during recombination. Finally, we found that defects in ASF1-RTT109–dependent acetylation of histone H3 lysine residue 56 (H3K56) resulted in increased accumulation of both GCRs and whole-chromosome duplications, and resulted in aneuploidy that tended to occur simultaneously with GCRs. Overall, we found that MLPA is a versatile technique for the rapid analysis of GCRs and can facilitate the genetic analysis of the pathways that prevent and promote GCRs and aneuploidy

Anaerobic ammonium-oxidising bacteria: A biological source of the bacteriohopanetetrol stereoisomer in marine sediments

Bacterially-derived bacteriohopanepolyols (BHPs) are abundant, well preserved lipids in modern and paleo-environments. Bacteriohopanetetrol (BHT) is a ubiquitously produced BHP while its less common stereoisomer (BHT isomer) has previously been associated with anoxic environments; however, its biological source remained unknown. We investigated the occurrence of BHPs in Golfo Dulce, an anoxic marine fjord-like enclosure located in Costa Rica. The distribution of BHT isomer in four sediment cores and a surface sediment transect closely followed the distribution of ladderane fatty acids, unique biomarkers for bacteria performing anaerobic ammonium oxidation (anammox). This suggests that BHT isomer and ladderane lipids likely shared the same biological source in Golfo Dulce. This was supported by examining the BHP lipid compositions of two enrichment cultures of a marine anammox species ('. Candidatus Scalindua profunda'), which were found to contain both BHT and BHT isomer. Remarkably, the BHT isomer was present in higher relative abundance than BHT. However, a non-marine anammox enrichment contained only BHT, which explains the infrequence of BHT isomer observations in terrestrial settings, and indicates that marine anammox bacteria are likely responsible for at least part of the environmentally-observed marine BHT isomer occurrences. Given the substantially greater residence time of BHPs in sediments, compared to ladderanes, BHT isomer is a potential biomarker for past anammox activity