Streptococcal quorum sensing peptide CSP-7 contributes to muscle inflammation and wasting.

Muscle wasting diseases, such as cancer cachexia and age-associated sarcopenia, have a profound and detrimental impact on functional independence, quality of life, and survival. Our understanding of the underlying mechanisms is currently limited, which has significantly hindered the development of targeted therapies. In this study, we explored the possibility that the streptococcal quorum sensing peptide Competence Stimulating Peptide 7 (CSP-7) might be a previously unidentified contributor to clinical muscle wasting. We found that CSP-7 selectively triggers muscle cell inflammation in vitro, specifically the release of IL-6. Furthermore, we demonstrated that CSP-7 can traverse the gastrointestinal barrier in vitro and is present in the systemic circulation in humans in vivo. Importantly, CSP-7 was associated with a muscle wasting phenotype in mice in vivo. Overall, our findings provide new mechanistic insights into the pathophysiology of muscle inflammation and wasting.

Accuracy, feasibility and predictive ability of different frailty instruments in an acute geriatric setting.

PURPOSE: To analyze the feasibility, accuracy and the ability of different frailty instruments to predict adverse outcomes. METHODS: A prospective cohort study was conducted in patients ≥ 70 years admitted to the acute care setting (ACS). Feasibility and prevalence of frailty were assessed by FRAIL, Clinical Frailty Scale (CFS), hand grip strength (HGS) and the Spanish Frailty-VIG. Receiver operator characteristic (ROC) curves and area under the curve (AUC) were performed to identify frailty according to each instrument, setting VIG as the reference. For each instrument, multiple logistic regressions were used to examine the effect of frailty on primary outcome (i.e., three-month mortality) and secondary outcomes (i.e., in-hospital mortality, length of stay, institutionalization, functional decline and 30-day readmission). RESULTS: A total of 185 patients were included, with a median age of 89 years. The feasibility of the instruments was 100%, except for HGS (67%). The prevalence of frailty varied from 65.2% (FRAIL) to 86.7% (VIG). AUCs against VIG ranged from 0.69 (95% confidence interval [CI] 0.57-0.81: FRAIL) to 0.77 (95% CI 63.5-90.2: CFS). Frail patients defined by FRAIL were 2.7times more likely to have a prolonged length of stay than non-frail patients (95% CI 1.385-5.416). Three-month mortality occurred more among frail patients, either defined by FRAIL (OR 2.5; 95% CI 1.072-5.881) or CFS (OR 3.7; 95% CI 1.255-10.812), than in non-frail patients. CONCLUSION: The four instruments had high feasibility providing variable prevalence of frailty. FRAIL and CFS predicted well for three-month mortality, and FRAIL also for length of stay. However, none of the instruments predicted for the other secondary outcomes of the study.

Clinical Characteristics, Frailty, and Mortality of Residents With COVID-19 in Nursing Homes of a Region of Madrid.

OBJECTIVES: To describe the clinical characteristics, 30-day mortality, and associated factors of patients living in nursing homes (NH) with COVID-19, from March 20 to June 1, 2020. DESIGN: This is a retrospective study. A geriatric hospital-based team acted as a consultant and coordinated the care of older people living in NHs from the hospital. SETTING AND PARTICIPANTS: A total of 630 patients aged 70 and older with Coronavirus Disease 2019 COVID-19 living in 55 NHs. METHODS: A logistic regression was performed to analyze the factors associated with mortality. In addition, Kaplan-Meier curves were applied according to mortality and its associated factors using the log-rank Mantel-Cox test. RESULTS: The diagnosis of COVID-19 was mainly made by clinical compatibility (N = 430). Median age was 87 years, 64.6% were women and 45.9% were transferred to be cared for at the hospital. A total of 282 patients died (44.7%) within the 30 days of first attention by the team. A severe form of COVID-19 occurred in 473 patients, and the most frequent symptoms were dyspnea (n = 332) and altered level of consciousness (n = 301). According to multiple logistic regression, male sex (P = .019), the Clinical Frailty Score (CFS) ≥6 (P = .004), dementia (P = .012), dyspnea (P < .001), and having a severe form of COVID-19 (P = .001), were associated with mortality, whereas age and care setting were not. CONCLUSIONS AND IMPLICATIONS: Mortality of the residents living in NHs with COVID-19 was almost 45%. The altered level of consciousness as an atypical presentation of COVID-19 should be considered in this population. A severe form of the disease, present in more than three-quarters of patients, was associated with mortality, apart from the male sex, CFS ≥6, dementia, and dyspnea, whereas age and care setting were not. These findings may also help to recognize patients in which the Advance Care Planning process is especially urgent to assist in the decisions about their care.

Effect of intravenous iron on functional outcomes in hip fracture: a randomised controlled trial.

OBJECTIVES: to determine the safety and effect of intravenous iron sucrose on functional outcomes, delirium, nosocomial infections and transfusion requirements in older patients with hip fracture. DESIGN: single-centre randomised, double-blind, placebo-controlled clinical trial. SETTING AND PARTICIPANTS: orthogeriatric share care service at an academic tertiary care hospital. A total of 253 patients were recruited: 126 patients were assigned to intravenous iron and 127 to placebo. METHODS: on days 1, 3 and 5 after admission, the iron group received 200 mg Venofer® (iron sucrose) in 100 ml saline and the placebo group 100 ml saline. The primary outcome was absolute functional gain, considered as Barthel index (BI) at discharge minus BI on admission. Secondary outcomes included incidence of postoperative delirium according to the confusion assessment method, proportion of patients recovering prior functional status at 3 months, postoperative transfusion requirements, haemoglobin at 3 months, incidence of nosocomial infections and safety. RESULTS: the median participant age was 87 (interquartile range, 82.5-91.5) years. Most patients were female (72.7%), and the median previous BI was 81(59-95). No significant effect of intravenous iron was observed for the primary outcome: the median AFG score was 17.1 points (4.8-23.3) in the intravenous iron group and 16 points (6-26) in the placebo group (P = 0.369). No significant treatment effects were observed for other functional outcomes or secondary end points. CONCLUSION: while we found no impact of intravenous iron sucrose on functional recovery, incidence of postoperative delirium, transfusion requirements, haemoglobin at 3 months, mortality and nosocomial infections rates in older patients with hip fracture, we did find that the intervention was safe.

Impact of delirium on short-term outcomes in hip fracture patients under a program of approach to delirium.

AIM: We aimed to investigate the impact of delirium on short-term outcomes in hip fracture patients. Special attention was given to patients with delirium and dementia. METHODS: A prospective observational cohort study was carried out in hip fracture patients aged ≥70 years who were admitted to a hospital unit where a multicomponents approach to delirium is established for all patients. Our population was split into delirium (n = 212) and non-delirium cohort (n = 171) according to the Confusion Assessment Method. Patients with a previous diagnosis of dementia in an outpatient appointment were also assessed within the delirium cohort. The utility of the rehabilitation was measured with the Absolute Functional Gain index. RESULTS: A total of 383 patients were entered into the study. The median age was 86 years, and most patients were women (78.8%). Delirium patients were older, presented a lower previous Barthel Index (BI), had higher rates of dementia and came more frequently from nursing homes. Comparative analysis did not show differences in mortality, complications, length of stay or walking ability between the cohorts. However, lower BI on discharge, lower Absolute Functional Gain and the presence of nosocomial infections were found more frequently in the delirium cohort. In multivariate analysis, only the BI on discharge (P = 0.010) was lower in delirium patients. Within the delirium cohort, those suffering from dementia had worse BI on discharge (P = 0.017) and lower Absolute Functional Gain (P = 0.019). CONCLUSIONS: Delirium was not associated with mortality, walking ability, length of stay and clinical complications in hip fracture patients. BI on discharge was the only short-term outcome affected. In the delirium cohort, those suffering from dementia showed worse rehabilitation results. Geriatr Gerontol Int 2020; 20: 130-137.

Registro de fracturas de cadera multicéntrico de unidades de Ortogeriatría de la Comunidad Autónoma de Madrid / Multi-centre register study of hip fractures in Orthogeriatric Units in the Community of Madrid (Spain)

Objetivos: Describir las características de pacientes con fractura de cadera (FC) ingresados desde enero de 2015 a diciembre de 2016 en ocho unidades de Ortogeriatría de hospitales públicos de la Comunidad Autónoma de Madrid. Material y métodos: Estudio descriptivo, prospectivo y multicéntrico. Se constituyó en 2014 un grupo de trabajo en FC; se invitó a la participación a todos los hospitales con algún tipo de asistencia conjunta entre Traumatología y Geriatría, participando los geriatras responsables de la unidad de Ortogeriatría de ocho hospitales. Se consensuó una base de datos con las variables con impacto en resultados de salud (sociodemográficas, clínicas y evolutivas durante el proceso asistencial). Resultados: Se incluyeron 3.995 pacientes; el 76,3% eran mujeres, y la edad media fue de 85,3años (rango 58-108años). El 67% fueron clasificados según el Physical Status Classification System de la American Society of Anesthesiologist (ASA) como III-IV. Se intervinieron el 96,7% de los pacientes (el 35,9% de ellos en las primeras 48h del ingreso, con una mediana de tiempo de retraso quirúrgico de 3días). La principal causa del retraso quirúrgico fueron los problemas logísticos en el 43,5% de los casos. La estancia hospitalaria media fue de 11,2días. Precisaron trasfusión el 53,1%. La mortalidad durante el ingreso fue del 5,3%. Conclusiones: Los registros de FC son un elemento imprescindible para conocer el proceso de atención a estos pacientes y poder aprender y mejorar la calidad asistencial. Nuestros resultados se adecúan a los de otros registros internacionales. Se debe mejorar el tiempo de espera prequirúrgica, consiguiendo intervenir en las primeras 48h a todos los pacientes sin datos de inestabilidad clínica. Igualmente se precisa mayor dotación de recursos de recuperación funcional y mayor uniformidad de estos

Objective: To describe the characteristics of patients with hip fractures admitted over a period of two years (from January 2015 to December 2016) in eight Orthogeriatric Units in public hospitals of the Community of Madrid. Material and method: This is a descriptive, prospective and multi-centre study. In 2014, all hospitals in Madrid providing joint Geriatric and Traumatology assistance were invited to a recently created orthogeriatric work group. Geriatricians in charge of the Orthogeriatric Unit from eight hospitals took part in this study. The participants established a database including all variables that influenced health outcomes (socio-demographic and clinical variables). Results: The study includes 3,995 patients, with a mean age of 85.3years (range: 58-108years old). Two-thirds of them were ASA (American Society Physical Status Classification System) III-IV. Almost all (96.7%) of the patients underwent a surgical operation, and 35.9% of them were operated during the first 48hours. The delay was mainly due to logistic problems (43.5%). The mean hospital stay was 11.2days. Just over half (53.1%) of the patients required a blood transfusion. In-hospital mortality was 5.3%. Discussion: Hip fracture registries are essential tools to monitor the healthcare process of these patients, as well as to improve the quality of care. Our results are similar to other records. It would be necessary to improve pre-operative time, which must be less than 48hours in patients without clinical instability. We also need more resources for functional recovery and more uniformity

Improving safety in blood transfusion using failure mode and effect analysis.

BACKGROUND: One of the medical areas where errors can have more serious consequences is the process of blood transfusion. We used failure mode and effect analysis (FMEA) for evaluating potential failures and improving transfusion safety in a medium-size urban hospital with a highly complex transfusion service. STUDY DESIGN AND METHODS: Each failure mode was evaluated using the likelihood of occurrence, severity of the effect, and probability of detection. The obtained results allowed each failure to be prioritized and decisions to be made in an organized manner to determine solutions. We define measures and indicators that allow the comparison of their results in a longer time period than most of the previous studies. RESULTS: The most important failures were those regarding 1) transmitting information about the transfusion request, 2) patient identification, 3) sample identification, 4) cross-matching ordered tests, 5) transfusing blood components, 6) completing and sending the transfusion control document, and 7) reporting of transfusion reactions. The application of the FMEA methodology allowed implementation of safety measures and monitoring of the measures using indicators, including the mandatory records of the hemovigilance system. There was a 56% improvement in the risk prioritization numbers in the second stage of the FMEA. CONCLUSION: FMEA allows for identification of factors that reduce safety in this hospital, analysis of the causes and consequences of these errors, design of corrective measures, and establishment of indicators to monitor their application. The FMEA methodology can help other institutions to identify their own specific vulnerabilities.

[Multi-centre register study of hip fractures in Orthogeriatric Units in the Community of Madrid (Spain)]. / Registro de fracturas de cadera multicéntrico de unidades de Ortogeriatría de la Comunidad Autónoma de Madrid.

OBJECTIVE: To describe the characteristics of patients with hip fractures admitted over a period of two years (from January 2015 to December 2016) in eight Orthogeriatric Units in public hospitals of the Community of Madrid. MATERIAL AND METHOD: This is a descriptive, prospective and multi-centre study. In 2014, all hospitals in Madrid providing joint Geriatric and Traumatology assistance were invited to a recently created orthogeriatric work group. Geriatricians in charge of the Orthogeriatric Unit from eight hospitals took part in this study. The participants established a database including all variables that influenced health outcomes (socio-demographic and clinical variables). RESULTS: The study includes 3,995 patients, with a mean age of 85.3years (range: 58-108years old). Two-thirds of them were ASA (American Society Physical Status Classification System) III-IV. Almost all (96.7%) of the patients underwent a surgical operation, and 35.9% of them were operated during the first 48hours. The delay was mainly due to logistic problems (43.5%). The mean hospital stay was 11.2days. Just over half (53.1%) of the patients required a blood transfusion. In-hospital mortality was 5.3%. DISCUSSION: Hip fracture registries are essential tools to monitor the healthcare process of these patients, as well as to improve the quality of care. Our results are similar to other records. It would be necessary to improve pre-operative time, which must be less than 48hours in patients without clinical instability. We also need more resources for functional recovery and more uniformity.

Impact of a patient blood management program within an Orthogeriatric care service.

BACKGROUND: Patient blood management (PBM) performs multidisciplinary strategies to optimize red blood cell (RBC) transfusion. Orthogeriatric share care models (surgeon and geriatrician manage the patient together from admission) have the goal of improving outcomes in hip fracture patients. MATERIAL AND METHODS: A prospective observational study was conducted. Patients aged ≥70 years undergoing hip fracture (HF) surgery were consecutively included. When admitted on the orthogeriatric service a PBM protocol was applied based on: perioperative antithrombotic management, intravenous iron sucrose administration and restrictive transfusion criteria. Risk factors, clinical and functional effects of transfusion and its requirements were assessed to audit our model. RESULTS: A total of 383 patients participated (women, 78.8%; median age, 86 (82-90) years). 210 patients (54.8%) were transfused. Age (OR = 1.055, 95% CI 1.017-1.094; p = 0.004) and Hemoglobin (Hb) level on admission (OR = 0.497, 95% CI 0.413-0.597; p < 0.001) were found to be significant risk factors for transfusion. Transfusion increased length of stay (b = 1.37, 95% CI 0.543-2.196; p = 0.001) but did not have an effect on other variables. DISCUSSION: The PBM program established within an orthogeriatric service showed positive outcomes in terms of clinical complications, mortality, delirium or functional recovery in transfused patients, whereas it did not impact on shorter length of stay. The risk of transfusion on admission was predicted with the lower Hb levels on admission, along with the age of the patients. New measurements as homogenous restrictive transfusion criteria, a single-unit RBC transfusion and the assessment of the intravenous iron efficacy are need to be applied as a result of the high transfusion requirements.

Evaluación de las complicaciones clínicas de los pacientes con fractura de cadera y sus factores asociados en una Unidad de Agudos de Ortogeriatría / Assessment of clinical complications and their associated factors in hip-fracture patients in an Acute Geriatric Orthopaedic Unit

Introducción. Las complicaciones clínicas en pacientes con fractura de cadera (FC) son elevadas y variables por su heterogéneo registro. El objetivo del estudio fue evaluar las complicaciones clínicas y sus factores asociados en pacientes con FC ingresados en la Unidad de Ortogeriatría de un hospital universitario de 283 camas que atiende un promedio de 200 FC/año. Material y métodos. Se incluyó a 383 pacientes ingresados consecutivamente en 2013 y en 2014 en un estudio analítico observacional prospectivo. Las complicaciones clínicas se definieron según recomendaciones avaladas por la AOTrauma Network (Red de Trabajo de la Asociación Internacional de Traumatólogos para el estudio de la osteosíntesis). Resultados. Doscientos setenta y tres pacientes (71,28%) presentaron alguna complicación. Las principales fueron el delirium (55,4%), la insuficiencia renal (15,4%) y las complicaciones cardiacas (12,3%). Se asociaron a la presencia de alguna complicación la clasificación ASA III-IV (OR=1,962; IC del 95%, 1,040-3,704; p = 0,038), un índice de Barthel al alta inferior (b = -3,572;IC del 95%, -0,866 a -0,104; p = 0,01), el incremento en la estancia media (b = 2,683; IC del 95%, 3,522-0,325; p < 0,001) y preoperatoria (OR = 1,165; IC del 95%, 1,050-1,294; p = 0,004). Conclusiones. Las complicaciones clínicas más frecuentes son el delirium, la insuficiencia renal y las complicaciones cardiacas. Una puntuación en la escala de ASA III-IV, una peor situación funcional al alta, así como una estancia preoperatoria y media prolongada, son factores asociados a la presencia de alguna complicación clínica. Las complicaciones cardiacas, pulmonares y digestivas son las principales causas de mortalidad en la unidad

Introduction. The incidence of clinical complications in hip fracture (HF) patients is high and variable due to their heterogeneous nature. The aim of the study was to assess the clinical complications and their associated factors in HF patients admitted to the Orthopaedic Geriatric Unit of a 283 bed University Hospital. An average of 200 HF patients is attended yearly. Material and methods. A prospective, observational and analytical study was conducted on 383 consecutive patients admitted to the unit during the years 2013 and 2014. Clinical complications were defined according to recommendations supported by the AOTrauma Network (International Network of Traumatologists for the Study of Osteosynthesis). Results. A total of 273 patients (71.28%) showed some clinical complication. The main ones were, delirium (55.4%), renal failure (15.4%), and cardiac complications (12.3%). An ASA III-IV score of OR = 1.962 (95% CI; 1.040-3.704, P=.038), lower Barthel index at discharge (b = -3.572, 95% CI -0.866 to -0.104, P=.01), the increase in pre-operative stay (OR = 1.165, 95% CI 1.050-1.294, P=.004) and an increased length of stay (b = 2.663, 95% CI 3.522-0.325; P<.001) were factors associated with clinical complications. Conclusions. Delirium, renal failure, and cardiac complications were the most frequent complications according the new recommendations. An ASA III-IV score, worse functional status at discharge, prolonged pre-operative period, and increased length of stay, were risk factors associated with clinical complications. Cardiac, pulmonary, and gastrointestinal complications were the main causes of mortality in the unit

[Assessment of clinical complications and their associated factors in hip-fracture patients in an Acute Geriatric Orthopaedic Unit]. / Evaluación de las complicaciones clínicas de los pacientes con fractura de cadera y sus factores asociados en una Unidad de Agudos de Ortogeriatría.

INTRODUCTION: The incidence of clinical complications in hip fracture (HF) patients is high and variable due to their heterogeneous nature. The aim of the study was to assess the clinical complications and their associated factors in HF patients admitted to the Orthopaedic Geriatric Unit of a 283 bed University Hospital. An average of 200 HF patients is attended yearly. MATERIAL AND METHODS: A prospective, observational and analytical study was conducted on 383 consecutive patients admitted to the unit during the years 2013 and 2014. Clinical complications were defined according to recommendations supported by the AOTrauma Network (International Network of Traumatologists for the Study of Osteosynthesis). RESULTS: A total of 273 patients (71.28%) showed some clinical complication. The main ones were, delirium (55.4%), renal failure (15.4%), and cardiac complications (12.3%). An ASA III-IV score of OR = 1.962 (95% CI; 1.040-3.704, P=.038), lower Barthel index at discharge (b = -3.572, 95% CI -0.866 to -0.104, P=.01), the increase in pre-operative stay (OR = 1.165, 95% CI 1.050-1.294, P=.004) and an increased length of stay (b = 2.663, 95% CI 3.522-0.325; P<.001) were factors associated with clinical complications. CONCLUSIONS: Delirium, renal failure, and cardiac complications were the most frequent complications according the new recommendations. An ASA III-IV score, worse functional status at discharge, prolonged pre-operative period, and increased length of stay, were risk factors associated with clinical complications. Cardiac, pulmonary, and gastrointestinal complications were the main causes of mortality in the unit.