Benefits of Structured Advance Care Plan in end-of-Life Care Planning among Older Oncology Patients: A Retrospective Pilot Study.

Objectives: Studies suggest that advance care planning (ACP) results in improved quality of life and reduced healthcare consumption. We assessed how the use of a structured advance care planning tool (ACPT) in oncology patients relates to their healthcare consumption before death, and to the match between preferred and actual place of death. Methods: We performed a pilot study at a teaching hospital in the Netherlands. Endpoints were 1) healthcare consumption at three and one month(s) before death, and 2) the match between preferred and actual place of death. Results: The study included 75 patients without an ACPT (group 1) and 59 patients with an ACPT (group 2) of whom the preferred place of care or death were documented at least three months before death in 15 patients (subgroup 2b). Compared to group 1, patients in group 2 had significantly more healthcare consumption. However, compared to group 1, patients in subgroup 2b underwent significantly less diagnostic (33.3% (n = 5) versus 69.3% (n = 52), p < 0.05) and laboratory tests (33.3% (n = 5) versus 62.7% (n = 47), p < 0.05) one month before death. Patients in subgroup 2b died at their preferred place more often (76.9%, n = 10) compared to patients in group 1 (58.3%, n = 7) (NS), which meant more deaths at home and less in-hospital-deaths. Conclusions: The results suggest that timely documentation of the preferred place of care or death in a structured ACPT may result in less healthcare consumption and a better match between the preferred and actual place of death.

Personal Devices to Monitor Physical Activity and Nutritional Intake After Colorectal Cancer Surgery: Feasibility Study.

BACKGROUND: The use of self-monitoring devices is promising for improving perioperative physical activity and nutritional intake. OBJECTIVE: This study aimed to assess the feasibility, usability, and acceptability of a physical activity tracker and digital food record in persons scheduled for colorectal cancer (CRC) surgery. METHODS: This observational cohort study was conducted at a large training hospital between November 2019 and November 2020. The study population consisted of persons with CRC between 18- and 75 years of age who were able to use a smartphone or tablet and scheduled for elective surgery with curative intent. Excluded were persons not proficient in Dutch or following a protein-restricted diet. Participants used an activity tracker (Fitbit Charge 3) from 4 weeks before until 6 weeks after surgery. In the week before surgery (preoperative) and the fifth week after surgery (postoperative), participants also used a food record for 1 week. They shared their experience regarding usability (system usability scale, range 0-100) and acceptability (net promoter score, range -100 to +100). RESULTS: In total, 28 persons were included (n=16, 57% male, mean age 61, SD 8 years), and 27 shared their experiences. Scores regarding the activity tracker were as follows: preoperative median system usability score, 85 (IQR 73-90); net promoter score, +65; postoperative median system usability score, 78 (IQR 68-85); net promotor score, +67. The net promoter scores regarding the food record were +37 (preoperative) and-7 (postoperative). CONCLUSIONS: The perioperative use of a physical activity tracker is considered feasible, usable, and acceptable by persons with CRC in this study. Preoperatively, the use of a digital food record was acceptable, and postoperatively, the acceptability decreased.

Coping Strategies Used by Older Adults to Deal with Contact Isolation in the Hospital during the COVID-19 Pandemic.

Due to the COVID-19 pandemic, many older adults have experienced contact isolation in a hospital setting which leads to separation from relatives, loss of freedom, and uncertainty regarding disease status. The objective of this study was to explore how older adults (55+) cope with contact isolation in a hospital setting during the COVID-19 pandemic in order to improve their physical and psychological wellbeing. The realist evaluation approach was used to formulate initial program theories on coping strategies used by (older) adults in an isolation setting. Twenty-one semi-structured interviews with older patients (n = 21) were analysed. This study revealed that both emotion-focused coping strategies as well as problem-focused coping strategies were used by older adults during contact isolation. The study also uncovered some new specific coping strategies. The results have useful implications for hospital staff seeking to improve the wellbeing of older adults in contact isolation in hospitals. Problem-focused coping strategies could be stimulated through staff performing care in a person-centred way. Trust in staff, as part of emotion-focused coping strategies, could be stimulated by improving the relationship between patients and staff.

Aortic pulse wave velocity in individuals of Asian and African ancestry: the HELISUR study.

Aortic pulse wave velocity has emerged as an important predictor of cardiovascular events, but data on ethnic differences in pulse wave velocity remain scarce. We explored differences in pulse wave velocity between people of Asian and African ancestry. Data were used from the cross-sectional Healthy Life in Suriname (HELISUR) study. Pulse wave velocity was estimated oscillometrically with the Arteriograph. We included 353 Asians and 364 Africans, aged respectively 44.9 (SD 13.5) and 42.8 (SD 14.1) years (p = 0.05). Crude median PWV was higher in Asians than in Africans (8.1 [IQR 6.9-10.1] m/s vs. 7.7 [IQR 6.5-9.3] m/s, p = 0.03), which was mainly attributable to an increased PWV in Asians ≥ 50 years (10.1 [IQR 8.7-11.8] m/s vs. 9.1 [IQR 7.9-11.3] m/s in Africans ≥50 years, p < 0.01). After adjustment for age and MAP in multivariable linear regression, Asians had a 1.044 [95% CI 1.019-1.072] m/s higher PWV compared to Africans. Additional adjustment for sex, glucose, total cholesterol, HDL cholesterol, triglycerides, BMI, and waist circumference did not substantially change the difference in pulse wave velocity between Asians and Africans (+1.044 [95% CI 1.016-1.074] m/s for Asians vs. Africans). In conclusion, persons of Asian ancestry have a higher pulse wave velocity than those of African ancestry. This persisted after adjustment for important cardiovascular risk parameters, including age and blood pressure. The higher PWV found in Asians could be consistent with their increased coronary heart disease risk.

Adequate and excessive food consumption in Suriname: a multiethnic middle-income country.

OBJECTIVES: To explore food consumption among different sex, age, ethnic, urban, education and income groups in Suriname. METHODS: Data from a cross-sectional population study (n = 5748; 15-64 year) were used. Food consumption was defined adequate if (1) fruit and vegetable intake was conformable to WHO recommendations, (2) mostly vegetable oil was used, and (3) whole-wheat products were used ≥ 3 days/week. Food consumption was defined excessive if 3 out of the following 5 items scored positive: consumption of (1) snack, (2) sweet, (3) fast food, or (4) soft drink ≥ 3 days/week, or (5) salt was always added while preparing a hot meal. RESULTS: 6.4% (95% CI 5.8-7.1) had an adequate and 21.9% (95% CI 20.9-23.0) an excessive food consumption pattern, with differences among ethnic groups (p < 0.05). Adequate consumption increased, while excessive consumption decreased with increasing age (p < 0.05). Both adequate and excessive consumption increased with higher degree of urbanization, level of education and income (p < 0.05). Except for level of education for adequate consumption, all characteristics remained in both models with adequate and excessive consumption as outcome (p < 0.09). CONCLUSIONS: Our study suggests interventions to promote adequate food consumption in general and to limit excessive food consumption mainly focused on youngsters and those living in urbanized areas of higher socioeconomic status.

Hypertension and Cardiovascular Risk Profile in a Middle-Income Setting: The HELISUR Study.

BACKGROUND: Hypertension is the leading risk factor responsible for premature death worldwide, but its burden has shifted to low- and middle-income countries. Therefore, we studied hypertension and cardiovascular risk in the population of Suriname, a middle-income country with a predominantly urban population of African and Asian ancestry. METHODS: A random sample of 1,800 noninstitutionalized men and women aged 18-70 years was selected to be interviewed at home and examined at the local hospital for cardiovascular risk factors, asymptomatic organ damage, and cardiovascular disease. RESULTS: The 1,157 participants examined (37% men) were mainly of self-defined Asian (43%) or African (39%) ancestry, mean age 43 years (SD 14). The majority of the population (71%) had hypertension or prehypertension, respectively, 40% and 31%. Furthermore, 72% was obese or overweight, while 63% had diabetes or prediabetes. Only 1% of the adult population had an optimal cardiovascular risk profile. Hypertension awareness, treatment, and control were respectively 68%, 56%, and 20%. In line with this, 22% of the adult population had asymptomatic organ damage, including increased arterial stiffness, left ventricular hypertrophy, microalbuminuria, or asymptomatic chronic kidney disease. CONCLUSIONS: In this first extensive cardiovascular assessment in the general population of this middle-income Caribbean country, high prevalence of hypertension with inadequate levels of treatment and control was predominant. The findings emphasize the need for collaborative effort from national and international bodies to prioritize the implementation of affordable and sustainable public health programs that combat the escalating hypertension and cardiovascular risk factor burden.

RhD negativity among pregnant women in multiethnic Suriname.

BACKGROUND: RhD negativity is distributed unevenly among different ethnicities. In this study we explored the frequencies of RhD negativity in pregnant women in multiethnic Suriname, along with screening results for red blood cell (RBC) antibodies in these women and their offspring. Results may help identify women at risk for hemolytic disease of the fetus and newborn. STUDY DESIGN AND METHODS: A retrospective study was performed in pregnant women who delivered at three major hospitals in Suriname between January 1, 2013, and December 31, 2014. RESULTS: The overall prevalences of RhD negativity among 8686 women was 4.3%. The percentages of RhD negativity in Maroons, Creoles, and Hindustani women were 7.2, 5.4, and 3.7%, respectively. Chinese and Javanese women had very low prevalences of 0.8 and 0.5%, respectively, and Amerindians showed no RhD negativity. Antibody screening was positive in six D- (five Maroons and one Creole) women and weakly positive in three women (two Creoles and one Maroon), making overall antibody prevalence 4.4%. In 15 (5.5%; 10 Maroons, four Creoles, one Chinese) newborns from D- mothers antibody screening was positive. CONCLUSION: In the multiethnic Surinamese population RhD negativity among pregnant women varied between 0.0 and 7.2% between ethnic groups. RBC antibodies were detected during pregnancy and in newborns in 4.4 and 5.5%, respectively.

Cardiac surgery-specific screening tool identifies preoperative undernutrition in cardiac surgery.

BACKGROUND: Loss of body tissue resulting in undernutrition can be caused by reduced food intake, altered metabolism, ageing, and physical inactivity. The predominant cause of undernutrition before cardiac operations is unknown. First, we explored the association of reduced food intake and inactivity with undernutrition in patients before elective cardiac operations. Second, we assessed if adding these reversible, cause-based items to the nutritional screening process improved diagnostic accuracy. METHODS: A prospective observational study was performed. Undernutrition was defined by low fat-free mass index (LFFMI) measured by bioelectrical impedance spectroscopy and/or unintended weight loss (UWL). Reduced food intake was defined as the patient having a decreased appetite over the previous month. Patients admitted to hospital preoperatively were assumed to be less physically active than patients awaiting cardiac operations at home. Using these data, we developed a new tool and compared this with an existing cardiac surgery-specific tool (Cardiac Surgery-Specific Malnutrition Universal Screening Tool [CSSM]). RESULTS: A total of 325 patients who underwent open cardiac operations were included. Reduced food intake and inactivity were associated with undernutrition (odds ratio [OR], 4.2; 95% confidence interval [CI], 2.1-8.5 and OR, 2.0; 95% CI, 1.0-4.0). Reduced food intake and inactivity were integrated with body mass index (BMI) and UWL into a new scoring system: the Cardiac Surgery-Specific Undernutrition Screening Tool (CSSUST). Sensitivity in identification of undernourished patients was considerably higher with the CSSUST (90%) than with the CSSM (71%) (receiver operating characteristic [ROC] curve-based area under the curve [AUC], 0.79; 95% CI, 0.73-0.86 and ROC AUC, 0.71; 95% CI, 0.63-0.80). CONCLUSIONS: Results suggest that reduced food intake and inactivity partly explain undernutrition before cardiac operations. Our new cause-based CSSUST, which includes reduced food intake and inactivity, is superior to existing tools in identifying undernutrition in patients undergoing cardiac operations.

The bioelectrical impedance phase angle as an indicator of undernutrition and adverse clinical outcome in cardiac surgical patients.

BACKGROUND & AIMS: In cardiac surgical patients, undernutrition increases the risk of adverse clinical outcome. We investigated whether the bioelectrical impedance phase angle is an indicator of undernutrition and clinical outcome in cardiac surgery. METHODS: In 325 cardiac surgical patients, we prospectively analyzed the associations between a preoperative low phase angle, measured by bioelectrical impedance spectroscopy, and well-established indicators of undernutrition such as body mass index (kg/m(2)), unintended weight loss, and fat free mass index (kg/m(2)), and muscle strength (handgrip strength (kg)), immune function (C-reactive protein and albumin), and adverse clinical outcomes. RESULTS: A low phase angle (<5.38°) was present in 29.8% (n = 96) of the patients, and was associated with low body mass index (p < 0.001), low fat free mass index (p < 0.001), and less handgrip strength (p = 0.063), but not with unintended weight loss or immune function. Furthermore, a preoperative low phase angle was associated with a prolonged intensive care unit and hospital stay (adj. hazard ratio: 0.68; 95%CI: 0.49-0.94; p = 0.020 and adj. hazard ratio: 0.74; 95%CI: 0.55-0.99; p = 0.048, respectively). CONCLUSIONS: A preoperative low bioelectrical impedance phase angle is associated with undernutrition, and increases the risk of adverse clinical outcome after cardiac surgery. The phase angle might help to identify undernourished cardiac surgical patients.

Postoperative loss of skeletal muscle mass, complications and quality of life in patients undergoing cardiac surgery.

OBJECTIVE: The objective of this study was to describe postoperative undernutrition in terms of postoperative losses of appendicular skeletal muscle mass (ASMM) with respect to complications, quality of life, readmission, and 1-y mortality after cardiac surgery. METHODS: Patients undergoing cardiac surgery were prospectively followed. ASMM was measured 2 wk before and 2 mo after surgery using dual-energy X-ray absorptiometry. ASMM consists of arm skeletal muscle mass (SMM) and leg SMM. The association between ≥5% of ASMM decrease and postoperative outcome was analyzed using the chi-square test. A similar approach was used to analyze arm SMM and leg SMM decreases separately. RESULTS: Twenty-nine patients were included (23 male, 34.5% ≥65 y old). Postoperatively, seven patients (24.1%) lost ≥5% ASMM. When analyzed separately, a ≥5% decrease in leg SMM was associated with a decrease in experienced vitality (odds ratio 13.0, 95% confidence interval 1.32-128.11, P = 0.03). In contrast, a ≥5% loss of arm SMM was associated with fewer in-hospital complications (odds ratio 0.20, 95% confidence interval 0.04-0.98, P = 0.04). These patients were characterized by a higher preoperative fat-free mass index (kilograms per meter squared; P = 0.01). CONCLUSIONS: The results suggest that a preoperatively higher fat-free mass index indicates better ability to cope with operative stress, resulting in fewer complications. In addition, postoperative loss of muscle mass was associated with decreased vitality. We advocate further research investigating the effect of preoperative and postoperative nutritional intervention combined with physical exercise programs to increase lean body mass and thereby improve postoperative recovery after cardiac surgery.

Accuracy of quick and easy undernutrition screening tools--Short Nutritional Assessment Questionnaire, Malnutrition Universal Screening Tool, and modified Malnutrition Universal Screening Tool--in patients undergoing cardiac surgery.

The objective of this study was to compare the quick-and-easy undernutrition screening tools, ie, Short Nutritional Assessment Questionnaire and Malnutrition Universal Screening Tool, in patients undergoing cardiac surgery with respect to their accuracy in detecting undernutrition measured by a low-fat free mass index (FFMI; calculated as kg/m(2)), and secondly, to assess their association with postoperative adverse outcomes. Between February 2008 and December 2009, a single-center observational cohort study was performed (n=325). A low FFMI was set at ≤14.6 in women and ≤16.7 in men measured using bioelectrical impedance spectroscopy. To compare the accuracy of the Malnutrition Universal Screening Tool and Short Nutritional Assessment Questionnaire in detecting low FFMI sensitivity, specificity, and other accuracy test characteristics were calculated. The associations between the Malnutrition Universal Screening Tool and Short Nutritional Assessment Questionnaire and adverse outcomes were analyzed using logistic regression analyses with odds ratios and 95% confidence intervals (CI) presented. Sensitivity and receiver operator characteristic-based area under the curve to detect low FFMI were 59% and 19%, and 0.71 (95% CI: 0.60 to 0.82) and 0.56 (95% CI: 0.44 to 0.68) for the Malnutrition Universal Screening Tool and Short Nutritional Assessment Questionnaire, respectively. Accuracy of the Malnutrition Universal Screening Tool improved when age and sex were added to the nutritional screening process (sensitivity 74%, area under the curve: 0.72 [95% CI: 0.62 to 0.82]). This modified version of the Malnutrition Universal Screening Tool, but not the original Malnutrition Universal Screening Tool or Short Nutritional Assessment Questionnaire, was associated with prolonged intensive care unit and hospital stay (odds ratio: 2.1, 95% CI: 1.3 to 3.4; odds ratio: 1.6, 95% CI: 1.0 to 2.7). The accuracy to detect a low FFMI was considerably higher for the Malnutrition Universal Screening Tool than for the Short Nutritional Assessment Questionnaire, although still marginal. Further research to evaluate the modified version of the Malnutrition Universal Screening Tool, ie, the cardiac surgery-specific Malnutrition Universal Screening Tool, is needed prior to implementing.

The impact of low preoperative fat-free body mass on infections and length of stay after cardiac surgery: a prospective cohort study.

OBJECTIVE: Several studies have shown low fat-free mass index to be a stronger predictor for mortality than low body mass index. The main aim of this study was to assess the still unknown association between preoperative low fat-free mass index and adverse cardiac surgical outcomes. METHODS: In a prospective observational study, fat-free mass index was determined by bioelectric impedance spectroscopy on hospital admission. Associations between low fat-free mass index and postoperative infections and mortality, as well as prolonged intensive care unit and hospital stays, were analyzed with logistic and Cox regression techniques. RESULTS: Between February 2008 and December 2009, 325 adult patients admitted for elective heart surgery were included. Analyses showed that low fat-free mass index, present in 8.3% of patients, was independently associated with occurrence of infections after cardiac surgery (18.5% vs 4.7%; adjusted odds ratio, 6.9; 95% confidence interval, 1.8-27.7; P = .01). Low fat-free mass index also tended to be associated with higher risk of longer postoperative intensive care unit stay (adjusted hazard ratio, 0.7; 95% confidence interval, 0.4-1.1; P = .09). When classifying patients as undernourished by traditional methods (body mass index ≤21.0 kg/m(2) or ≥10% weight loss in preceding 6 months), half of patients with low fat-free mass index were misclassified as well nourished. CONCLUSIONS: Low fat-free mass index is associated with increased occurrence of adverse outcomes after cardiac surgery. We advocate fat-free mass index as the leading parameter in classifying and treating undernourished cardiac surgical patients, which might improve recovery rates after cardiac surgery.

Rationale and design of a proof-of-concept trial investigating the effect of uninterrupted perioperative (par)enteral nutrition on amino acid profile, cardiomyocytes structure, and cardiac perfusion and metabolism of patients undergoing coronary artery bypass grafting.

BACKGROUND: Malnutrition is very common in patients undergoing cardiac surgery. Malnutrition can change myocardial substrate utilization which can induce adverse effects on myocardial metabolism and function. We aim to investigate the hypothesis that there is a disturbed amino acids profile in the cardiac surgical patient which can be normalized by (par)enteral nutrition before, during and after surgery, subsequently improving cardiomyocyte structure, cardiac perfusion and glucose metabolism. METHODS/DESIGN: This randomized controlled intervention study investigates the effect of uninterrupted perioperative (par)enteral nutrition on cardiac function in 48 patients undergoing coronary artery bypass grafting. Patients are given enteral nutrition (n = 16) or parenteral nutrition (n = 16), at least two days before, during, and two days after coronary artery bypass grafting, or are treated according to the standard guidelines (control) (n = 16). We will illustrate the effect of (par)enteral nutrition on differences in concentrations of amino acids and asymmetric dimethylarginine and in activity of dimethylarginine dimethylaminohydrolase and arginase in cardiac tissue and blood plasma. In addition, cardiomyocyte structure by histological, immuno-histochemical and ultrastructural analysis will be compared between the (par)enteral and control group. Furthermore, differences in cardiac perfusion and global left ventricular function and glucose metabolism, and their changes after coronary artery bypass grafting are evaluated by electrocardiography-gated myocardial perfusion scintigraphy and ¹8F-fluorodeoxy-glucose positron emission tomography respectively. Finally, fat free mass is measured before and after intervention with bioelectrical impedance spectrometry in order to evaluate nutritional status. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR2183.

Preoperative and postoperative agreement in fat free mass (FFM) between bioelectrical impedance spectroscopy (BIS) and dual-energy X-ray absorptiometry (DXA) in patients undergoing cardiac surgery.

BACKGROUND & AIMS: To measure undernutrition in terms of fat free mass (FFM), there are several options. The aim of this study was to assess agreement in FFM between the portable, bedside bioelectrical impedance spectrometry (BIS) and relatively expensive, non-portable dual-energy X-ray absorptiometry (DXA) in patients undergoing cardiac surgery. METHODS: In a prospective study, body composition measurements by BIS and DXA were performed two weeks prior and two months after cardiac surgery. Preoperative and postoperative agreement in FFM between BIS and DXA were analyzed with Bland and Altman plots. RESULTS: Twenty-six patients were analyzed. BIS overestimated preoperative and postoperative FFM by 2 kg compared to DXA (2.3 kg (95%CI: -3.5-8.1 kg) and 2.1 kg (95%CI: -4.5-8.7 kg), respectively). BIS underestimated FFM change by -0.5% (95%CI: -8.4-7.5%). CONCLUSIONS: There is a large inter-individual variation between BIS and DXA. This hinders the interchange-ability of BIS and DXA in routine clinical practice and may lead to misclassifications and thereby inappropriate nutritional treatment and possible postoperative complications. To evaluate nutritional therapy in patients undergoing cardiac surgery, we advocate the use of DXA assessed FFM in parallel to BIS assessed extracellular and intracellular water and FFM.

Preoperative protein and energy intake and postoperative complications in well-nourished, non-hospitalized elderly cardiac surgery patients.

BACKGROUND & AIMS: Little is known about the impact of preoperative protein or energy intake in relation to the occurrence of postoperative complications in patients who are not undernourished but cannot keep up their daily protein or energy requirements prior to cardiac surgery. Therefore, a prospective study on intake in preoperatively well-nourished, non-hospitalized cardiac surgery patients (>or= 65 y) was carried out. METHODS: Between December 2004 and November 2005 preoperative protein and energy intake and postoperative outcome data were collected from 100 consecutive patients undergoing cardiac surgery. RESULTS: Comparison of low protein intake (0.98 g/kg/d) showed a low protein intake did not result in more complications or prolonged length of stay. In low-risk operation patients in particular, a high-energy intake (>22 kcal/kg/d) resulted in more postoperative complications than a low energy intake (

Preoperative unintended weight loss and low body mass index in relation to complications and length of stay after cardiac surgery.

BACKGROUND: Several studies reported increased adverse outcomes after cardiac surgery in patients with low body mass index (BMI; in kg/m(2)). Little is known yet, however, about the effect of preoperative unintended weight loss (UWL) in cardiac surgery patients. OBJECTIVE: We explored the prevalence and effect of UWL in view of low BMI and vice versa adjusted for a validated set of preoperative risks, inflammatory activity, and duration of extracorporeal circulation on postoperative adverse outcome. DESIGN: A prospective cohort study was performed. Nutritional data of cardiac surgery patients were collected within 24 h of admission and linked to the standard postoperative complication registration database. RESULTS: The cohort consisted of 331 cases. Multivariate logistic regression analyses showed that preoperative UWL of >or=10% in the past 6 mo (>or=10%UWLin6m) was associated with a prolonged length of stay in the hospital independent from low BMI [odds ratio (OR): 7.06; 95% CI: 1.78, 28.04]. Preoperative BMI or=10%UWLin6m (OR: 4.62; 95% CI: 1.20, 17.82; and OR: 5.27; 95% CI: 1.28, 21.76, respectively). Preoperative undernutrition in cardiac surgery patients (>or=10%UWLin6m or BMI or=10%UWLin6m or BMI