Impact of social care supply on healthcare utilisation by older adults: a systematic review and meta-analysis.

Objective: to investigate the impact of the availability and supply of social care on healthcare utilisation (HCU) by older adults in high income countries. Design: systematic review and meta-analysis. Data sources: medline, EMBASE, Scopus, Health Management Information Consortium, Cochrane Database of Systematic Reviews, NIHR Health Technology Assessment, NHS Economic Evaluation Database, Database of Abstracts of Reviews of Effectiveness, SCIE Online and ASSIA. Searches were carried out October 2016 (updated April 2017 and May 2018). (PROSPERO CRD42016050772). Study selection: observational studies from high income countries, published after 2000 examining the relationship between the availability of social care (support at home or in care homes with or without nursing) and healthcare utilisation by adults >60 years. Studies were quality assessed. Results: twelve studies were included from 11,757 citations; ten were eligible for meta-analysis. Most studies (7/12) were from the UK. All reported analysis of administrative data. Seven studies were rated good in quality, one fair and four poor. Higher social care expenditure and greater availability of nursing and residential care were associated with fewer hospital readmissions, fewer delayed discharges, reduced length of stay and expenditure on secondary healthcare services. The overall direction of evidence was consistent, but effect sizes could not be confidently quantified. Little evidence examined the influence of home-based social care, and no data was found on primary care use. Conclusions: adequate availability of social care has the potential to reduce demand on secondary health services. At a time of financial stringencies, this is an important message for policy-makers.

Medial-lateral centre of mass displacement and base of support are equally good predictors of metabolic cost in amputee walking.

Amputees are known to walk with greater metabolic cost than able-bodied individuals and establishing predictors of metabolic cost from kinematic measures, such as centre of mass (CoM) motion, during walking are important from a rehabilitative perspective, as they can provide quantifiable measures to target during gait rehabilitation in amputees. While it is known that vertical CoM motion poorly predicts metabolic cost, CoM motion in the medial-lateral (ML) and anterior-posterior directions have not been investigated in the context of gait efficiency in the amputee population. Therefore, the aims of this study were to investigate the relationship between CoM motion in all three directions of motion, base of support and walking speed, and the metabolic cost of walking in both able-bodied individuals and different levels of lower limb amputee. 37 individuals were recruited to form groups of controls, unilateral above- and below-knee, and bilateral above-knee amputees respectively. Full-body optical motion and oxygen consumption data were collected during walking at a self-selected speed. CoM position was taken as the mass-weighted average of all body segments and compared to each individual's net non-dimensional metabolic cost. Base of support and ML CoM displacement were the strongest correlates to metabolic cost and the positive correlations suggest increased ML CoM displacement or Base of support will reduce walking efficiency. Rehabilitation protocols which indirectly reduce these indicators, rather than vertical CoM displacement will likely show improvements in amputee walking efficiency.

Energy flow analysis of amputee walking shows a proximally-directed transfer of energy in intact limbs, compared to a distally-directed transfer in prosthetic limbs at push-off.

Reduced capacity and increased metabolic cost of walking occurs in amputees, despite advances in prosthetic componentry. Joint powers can quantify deficiencies in prosthetic gait, but do not reveal how energy is exchanged between limb segments. This study aimed to quantify these energy exchanges during amputee walking. Optical motion and forceplate data collected during walking at a self-selected speed for cohorts of 10 controls, 10 unilateral trans-tibial, 10 unilateral trans-femoral and 10 bilateral trans-femoral amputees were used to determine the energy exchanges between lower limb segments. At push-off, consistent thigh and shank segment powers were observed between amputee groups (1.12W/kg vs. 1.05W/kg for intact limbs and 0.97W/kg vs. 0.99W/kg for prosthetic limbs), and reduced prosthetic ankle power, particularly in trans-femoral amputees (3.12W/kg vs. 0.87W/kg). Proximally-directed energy exchange was observed in the intact limbs of amputees and controls, while prosthetic limbs displayed distally-directed energy exchanges at the knee and hip. This study used energy flow analysis to show a reversal in the direction in which energy is exchanged between prosthetic limb segments at push-off. This reversal was required to provide sufficient energy to propel the limb segments and is likely a direct result of the lack of push-off power at the prosthetic ankle, particularly in trans-femoral amputees, and leads to their increased metabolic cost of walking.

A modern-day solution to a 100-year-old problem: the use of a Bespoke Off-loading Brace in the rehabilitation of 'Deck-Slap' and other high-energy lower limb injuries.

'Deck-Slap' is an injury pattern first described at the Battle of Jutland; it is still relevant today, with anti-vehicle mines a significant threat to Coalition troops. The effect of a device exploding beneath a vehicle produces a wave of high energy that is rapidly transmitted through the steel floor; this causes significant axial loading of lower limbs often resulting in severe fractures (notably of the calcaneum). Recent advancements in orthopaedic surgery have allowed for limbs that were destined for immediate amputation following significant trauma to be salvaged. However, despite intense rehabilitation, many of these salvaged limbs have subsequently gone on to delayed amputation, as functional outcomes are often poor. Technologically advanced prosthetic devices are available that afford good quality of life and allow for increased activity levels; these devices are, however, expensive to procure and maintain. This report describes a United Kingdom (UK) Armed Forces soldier who suffered a typical 'deck-slap' injury in Afghanistan with subsequent limb salvage. The use of the Bespoke Off-loading Brace (BOB) is discussed. The results presented here indicate that the biomechanical function of a patient with this type of injury improves when wearing the BOB. Further studies are needed to assess long-term clinical outcomes and the functional benefit of the device as a viable and cost-effective alternative to delayed limb amputation.

Programmed cell death in normal fetal rat lung development.

Lung development is a coordinated process regulated by the interactions of extracellular and intracellular factors, yet little is known about the process of programmed cell death during lung development. To study this question, we examined fetal rat lung from the pseudoglandular period (gestational day 15) to the day of birth (gestational day 21) using BrdU incorporation into DNA as a proliferative marker, while in parallel examining several markers of programmed cell death including terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL), DNA "laddering, " and expression of programmed cell death pathway proteins. Cell proliferation was ongoing throughout fetal days 15 to 21 with a decrease in proliferation over days 20 and 21. Programmed cell death in fetal lung also appeared to be present at all ages examined, but demonstrated 2 peaks of activity at fetal days 15 and 18 to 20. Bcl-XL expression was detected on fetal days 15 to 21, with diminished expression on days E15 to E18. Cleaved poly(ADP-ribose)polymerase (PARP), activated caspase-3, Bax, and Bad were increased on days 18 to 20. We conclude that proliferation is the primary process driving fetal lung development with programmed cell death occurring throughout the lung developmental process to refine structural remodeling.

Two further British families with the 'cryohydrocytosis' form of hereditary stomatocytosis.

We describe two families with the 'cryohydrocytosis' form of stomatocytosis. Both show a mild stomatocytic anaemia with Hb levels of 12-16 g/dl and reticulocyte counts of 4.3-24%, with very marked autohaemolysis at refrigerator temperatures and pseudohyperkalaemia as a result of loss of K from red cells on storage at room temperature. The ouabain + bumetanide-insensitive 'passive leak' K influx showed a 'U'-shaped temperature dependence, with a minimum at 23 degrees C. In one family, there was consistent variation in haematological severity within the pedigree. In the other, the parents of the proposita were normal, but all three of her children were affected, consistent with a new mutation of a dominant condition. Cold storage of the red cells led to a very marked increase in osmotic fragility and macrospherocytosis, explaining why a diagnosis of 'hereditary spherocytosis' can easily be reached in these pedigrees.

Familial pseudohyperkalaemia Chiswick: a novel congenital thermotropic variant of K and Na transport across the human red cell membrane.

Two families with inherited abnormalities in Na and K transport across the red cell membrane are described. Both presented with 'pseudohyperkalaemia' as a result of loss of K from the red cells on storage at room temperature. Routine haematology was essentially normal, except for macrocytosis in one family. Studies of the temperature dependence of the passive leak to K showed a novel shoulder pattern with a minimum at 25 degrees C, a maximum at 10 degrees C, followed by a further fall. As in other cases of red cell-based pseudohyperkalaemia, the abnormal temperature dependence of this 'leak' flux could be held to account for the loss of K from the cells at room temperature. These cases represent a novel variant of the temperature dependence of the passive leak of K and Na across the red cell membrane, and can be classified as a mild, non-haemolytic form of the group known as the hereditary stomatocytosis and allied disorders'.

Prospective memory, everyday cognitive failure and central executive function in recreational users of Ecstasy.

Chronic use of MDMA (3,4-methylenedioxymethamphetamine), or Ecstasy, is believed to lead to impaired psychological performance, including well-documented decrements in laboratory and field tests of retrospective memory. Less is known about the impact of Ecstasy on aspects of 'everyday' memory, despite obvious concerns about such effects. The three studies reported here focused on the impact of chronic Ecstasy use on prospective memory (PM), associated central executive function and other aspects of day-to-day cognition. In study 1 46 regular Ecstasy users were compared with 46 Ecstasy-free controls using the Prospective Memory Questionnaire (PMQ). Ecstasy users reported significantly more errors in PM (remembering to do something in the future); these findings persisted after controlling for other drug use and the number of strategies used to aid memory. No difference was found between representative subgroups on the Lies Scale of the Eysenck Personality Questionnaire. In study 2 a different group of 30 regular Ecstasy users and 37 Ecstasy-free controls was assessed on the PMQ and on a central executive task comprising verbal fluency measures. The results confirmed the significant impairments in long- and short-term PM and revealed corresponding impairments in verbal fluency. In study 3 15 Ecstasy users, 15 cannabis users and 15 non-drug users were assessed using the Cognitive Failures Questionnaire, which requires participants to provide ratings of the frequency of various day-to-day cognitive slips. The results indicate that the Ecstasy users did not perceive their general cognitive performance to be worse than that of controls. Taken together, these results suggest that Ecstasy users have impaired PM that cannot be explained by an increased propensity to exaggerate cognitive failures. These may be attributable, in part, to central executive deficits that are due to frontal lobe damage associated with Ecstasy use. Copyright 2001 John Wiley & Sons, Ltd.

Regulation of the rat BB1 RNA during normal rat lung development.

BB1 was recently cloned from the WI-38 human fetal lung cell line. Human BB1 (hBB1) is expressed by multiple tissues, including lung. Because inhibition of BB1 translation using antisense oligodeoxynucleotides resulted in prevention of G1 traversal in cultured cells, we hypothesized that BB1 gene expression would be regulated during lung development with greater expression during periods of active lung growth. To gain insight into the expression of BB1 during lung development, a rat BB1 (rBB1) homologue was cloned and used in Northern hybridization analyses and in situ hybridization histochemistry (ISHH). Northern hybridization analyses of fetal and postnatal rat lung demonstrate that rBB1 RNA abundance is relatively low on fetal days E17 through E19, with a small peak of expression occurring on fetal day E20, then increases at birth with peak expression in adult lung. ISHH correlates with the Northern hybridization data and reveals rBB1 RNA expression throughout lung from E17 to E21 in both epithelium and mesenchyme. In postnatal lung, more intense expression of BB1 was observed than in fetal lung, localizing BB1 transcripts to proximal and distal airways and mesenchymal cells surrounding airways. Proliferating cell nuclear antigen (PCNA) was identified in lung sections adjacent to those used for ISHH and it was found that BB1 expression was present in PCNA-positive cells; however, BB1 expression was not limited to PCNA-positive cells in either the fetal or postnatal periods. This was most apparent in adult (60-day) rat lung where essentially no PCNA-positive cells were detected, but intense BB1 expression was detected in airway epithelium and surrounding mesenchyme. These studies demonstrate developmental regulation of BB1 during lung development. The findings are consistent with BB1 action in cell growth-related processes of fetal and early postnatal lung; however, the distribution of BB1 expression in relation to PCNA localization suggests that BB1 participates in cellular functions in addition to cell proliferation.

Differentiating among research, evaluation and measures to assure quality.

This article explores the similarities, differences and overlaps among research, evaluation and quality measurement. Criteria for determining the differences are offered as a quick guide to differentiating among them. These criteria are the purpose of the project, generalizability, intended use of the findings, intended subjects and intent to prove causation. Determining the key differences among research, evaluation and quality measurement facilitates the choice of restrictions, supports and reporting process that should be applied to each.

The challenge of evaluating programs in a large health sciences centre.

This article illustrates how the logic model and a course on program evaluation at a large health sciences centre were instrumental in preparing staff to evaluate their own programs. Staff and physicians need basic skills in program evaluation. The logic model is a simple yet useful tool in helping to identify key measurables. A short course to teach the theory and practice of logic models, evaluation design, choice and design of measures, and data analysis has been shown to be a practical solution in preparing staff and physicians to evaluate their own programs.

Do wrist guards protect against fractures?

STUDY OBJECTIVE: To determine whether wrist guards increase the fracture threshold for wrist and forearm fractures. METHODS: We conducted a controlled, blinded experimental study using matched cadaveric arms-one fitted with a wrist guard-dropped with the use of a device designed to simulate a fall. We measured the mean number of drops before the occurrence of fracture, mean height and velocity change to fracture, mean kinetic energy, mean peak acceleration (in Gs), and summed impulse [weight (kilograms) x delta velocity (meters/second)] to fracture with and without wrist guards. Fracture severity was compared with the use of an ordinal ranking system and analyzed with the Mann-Whitney rank-sum test. RESULTS: Wrist guards were associated with a statistically significant increase in the number of drops, mean drop height, mean kinetic energy, and summed impulse required to cause a fracture. Fractures also tended to be less severe when wrist guards were used. CONCLUSION: The biomechanical evidence of a protective effect of wrist guards against wrist fractures seen in this study, coupled with previous epidemiologic evidence, is strong enough to warrant pediatricians, family practitioners, and emergency physicians to counsel skaters to use these devices when using roller skates, skateboards, or in-line skates.

Evaluating a palliative care program: methodology and limitations.

The article describes an evaluation of a palliative care service in a regional and tertiary care facility. The service components are described. The four outcomes chosen for evaluation were: (a) symptom relief; (b) satisfaction with care for patients/families; (c) utilization of community resources; (d) good nursing morale and low staff stress. Quality of life was measured using a symptom distress scale; satisfaction using an adapted Kristjanson FAMCARE scale; community resources with opinion and satisfaction surveys; and staff morale and stress with the Maslach Bumout Inventory and Latack's Coping Questionnaire. Results showed that overall symptom distress was reduced. Patients/families were generally satisfied, with some areas needing attention. Physicians were generally satisfied and believed patients/families benefited from the psychosocial support, respite, and education/information. Nurses felt they had the time, energy, resources and support to give quality care.

Regulation of the insulin-like growth factor system during normal rat lung development.

Insulin-like growth factor (IGF)-I and IGF-II are small peptide growth factors that interact with a specific membrane receptor, the type 1 IGF receptor, to stimulate cellular proliferation and/or differentiation. The actions of these growth factors and their availability to their receptors are modulated by specific binding proteins, IGF binding protein (IGFBP)-1 through -6, which together with the IGFs and IGF receptors form the IGF system. We have analyzed RNA extracted from fetal (gestation day 16 [E16] through 22 [E22]) and adult (60-day-old) rat lung for expression of each component of the IGF system. IGF-I and -II RNAs are expressed throughout fetal development. IGF-I mRNA remained relatively constant in fetal and adult lung, whereas IGF-II RNA decreased in later gestation to levels below detection by Northern analyses in adult lung. Type 1 IGF receptor expression varied little through all ages studied, whereas the type 2 IGF receptor RNA displayed developmental regulation with a decline in expression with advancing age. IGFBP-1 transcripts were not detected in fetal or adult lung. IGFBP-2 RNA was expressed from E16 to E22, although its abundance decreased in late gestation and in adult lung, with the lowest levels of expression on day E22. IGFBP-3, -4, and -5 had similar profiles of RNA abundance, with fetuses at ages E21 and E22 displaying higher levels of transcript abundance as compared with those aged E17 to E20; the lowest RNA abundance was seen at E20.(ABSTRACT TRUNCATED AT 250 WORDS)

Cloning and characterization of a novel RNA involved in cellular growth regulation.

During the course of antisense oligodeoxynucleotide (oligo) inhibition experiments investigating the role of insulin-like growth factor I (IGF-I) in the WI-38 cell cycle, we found that a sense-strand oligo (S oligo), used as a control, inhibited DNA synthesis 90 to 95%. S1 nuclease protection assays demonstrated that this S oligo formed intracellular duplexes with WI-38 RNA, and Northern (RNA) hybridization analyses demonstrated specific hybridization of this 32P-labeled S oligo to 1.8-, 2.3-, and 3.2-kb RNAs. We have cloned and sequenced a 2,251-bp cDNA, designated BB1, corresponding to the 2.3-kb RNA. Decoding of the BB1 cDNA sequence reveals several open reading frames arranged in a motif similar to that seen in proteins subject to translational control mechanisms. Homology searches of nucleic acid and protein data bases reveal no significant homology of BB1 with known sequences other than a 234-bp region in the BB1 5' untranslated region that shared 97% homology with a region in the 3' untranslated region of the human cdc42 mRNA. S1 nuclease protection analyses performed with IGF-I gene fragments and computer homology searches demonstrated that the BB1 RNA does not derive from transcription from the opposite strand of the IGF-I gene. Northern hybridization analyses of RNA extracted from serum-starved HeLa S3 cells demonstrated that steady-state BB1 RNA levels increased upon serum growth stimulation, with steady-state levels peaking 4 h after release from the block induced by serum starvation. Antisense oligo inhibition experiments using specific BB1 antisense oligos targeted to the putative open reading frames of the BB1 RNA reduce DNA synthesis of HeLa S3 cells to 15% of control levels, indicating that the BB1 RNA is essential for cell cycle traversal and, as such, encodes a growth-reguLating gene product.

Limited effect of three types of daily stress on rat free-running locomotor rhythms.

The effects of three types of stress/arousal on rat free-running circadian locomotor rhythms in constant darkness were investigated over a 93-day treatment period. Rats were subjected to 30-min daily immobilisation stress or 30-min novelty or to brief handling (n = 10/group). Seven of the 30 rats exhibited some changes in circadian parameters. Three rats (two immobilised, one handling) showed entrainment, three rats (one from each group) showed a change in tau, and one rat (novelty) showed a phase advance. Thus, in total, 30% immobilisation, 20% percent novelty, and 20% handled rats showed circadian changes. These group changes paralleled changes in faecal boli and body weight, which were taken as indirect indices of the level of stress. Five of the seven changes took place when the end of the active phase (alpha), i.e., subjective dawn, coincided with the time of treatment and the other two when the onset of sigma, i.e., subjective dusk, coincided. Rat circadian locomotor rhythms appear much less susceptible to stress/arousal than those reported for hamsters.

Insulin-like growth factor-I (IGF-I) antisense oligodeoxynucleotide mediated inhibition of DNA synthesis by WI-38 cells: evidence for autocrine actions of IGF-I.

Insulin-like growth factor-I (IGF-I) is elaborated into culture medium by WI-38 cells, a human embryonic lung fibroblast cell line, and may participate in the autocrine stimulation of DNA synthesis. We have confirmed the expression of IGF-I by these cells and documented that they express the type 1 IGF receptor and a number of IGF-binding proteins. In situ hybridization histochemistry demonstrated relatively uniform expression of IGF-I and type 1 IGF receptor transcripts among WI-38 cells. To determine whether WI-38-synthesized IGF-I exerted mitogenic effects, a 15-base oligodeoxynucleotide complementary to the 5'IGF-I mRNA sequence (IGF-I AS-Oligo), including the translation start site, was incubated with cultured cells in an attempt to inhibit IGF-I synthesis. The IGF-I AS-Oligo was stable in cell culture, formed intracellular duplexes with IGF-I mRNA, and at 2 microM reduced IGF-I in conditioned medium by 83%. The IGF-I AS-Oligo also inhibited [3H]thymidine incorporation into DNA in a dose-dependent fashion (by 77% at 2 microM and by 95% at 20 microM). This reduction in DNA synthesis was prevented when the medium was supplemented with 100 ng/ml IGF-I. The oligomer also decreased the abundance of IGF-binding proteins in conditioned medium. The IGF-I AS-Oligo appears to exert its effects by blocking IGF-I mRNA translation, rather than blocking transcription or initiating RNase-H activity, because the abundance of IGF-I transcripts was not decreased in its presence. These findings confirm an essential role for IGF-I in WI-38 cell DNA synthesis and are consistent with autocrine actions by WI-38 cell IGF-I.