Nutritional interventions for the management of frailty in older adults: systematic review and meta-analysis of randomized clinical trials.

CONTEXT: Although nutrition is considered an important intervention for the management of frailty, the actual effectiveness of interventions addressing nutrition in frail older people remains unclear. OBJECTIVE: The aim for this systematic review was to appraise the evidence regarding the effectiveness of nutritional interventions for the management of frailty in older adults. DATA EXTRACTION: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Web of Science, and Latin American and Caribbean Health Sciences Literature databases were searched from January 2001 to November 2019. Two independent reviewers extracted relevant data. From 2370 initial records, 19 publications presenting data from 17 studies (1564 individuals; follow-up: 7-96 weeks) were included. DATA ANALYSIS: None of the Bayesian random-effects meta-analyses comparing nutritional supplements with placebo regarding mortality, body mass index, weight, frailty status, muscle strength, gait speed, body composition, and cognitive function showed statistically significant differences. The same applies to a single meta-analysis comparing nutritional education with general health advice regarding muscle strength. CONCLUSION: Our results suggest, mostly with low to very low degrees of certainty, that nutritional supplements or nutritional education delivered in isolation may not be effective for the management of frailty in older people. REVIEW REGISTRATION NUMBER: CRD42018111510 (PROSPERO).

To What Extent Do Physician Orders for Life-Sustaining Treatment (POLST) Reflect Patients' Preferences for Care at the End of Life?

OBJECTIVE: To assess whether medical orders within Physician Orders for Life-Sustaining Treatment (POLST) forms reflect patients' preferences for care at the end of life. DESIGN: This cross-sectional study assessed the agreement between medical orders in POLST forms and the free-form text documentation of an advance care planning conversation performed by an independent researcher during a single episode of hospitalization. SETTING AND PARTICIPANTS: Inpatients at a single public university hospital, aged 21 years or older, and for whom one of their attending physicians provided a negative answer to the following question: "Would I be surprised if this patient died in the next year?" Data collection occurred between October 2016 and September 2017. MEASURES: Agreement between medical orders in POLST forms and the free-form text documentation of an advance care planning conversation was measured by kappa statistics. RESULTS: Sixty-two patients were interviewed. Patients' median (interquartile range) age was 62 (56-70) years, and 21 patients (34%) were women. Overall, in 7 (11%) cases, disagreement in at least 1 medical order for life-sustaining treatment was found between POLST forms and the content of the independent advance care planning conversation. The kappa statistic for cardiopulmonary resuscitation was 0.92 [95% confidence interval (CI): 0.82-1.00]; for level of medical intervention, 0.90 (95% CI: 0.81-0.99); and for artificially administered nutrition, 0.87 (95% CI: 0.75-0.98). CONCLUSIONS AND IMPLICATIONS: The high level of agreement between medical orders in POLST forms and the documentation in an independent advance care planning conversation offers further support for the POLST paradigm. In addition, the finding that the agreement was not 100% underscores the need to confirm frequently that POLST medical orders accurately reflect patients' current values and preferences of care.

Sufentanil during anesthetic induction of remifentanil-based total intravenous anesthesia: a randomized controlled trial / Sufentanil durante a indução da anestesia intravenosa total à base de remifentanil: ensaio clínico randômico

Abstract Background Postoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half-life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil-based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil-based total intravenous anesthesia. Methods Forty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil-based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient-controlled analgesia pump. Self-reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery. Results The mean difference between the sufentanil and control groups regarding morphine consumption in the post-anesthetic care unit and at 12, 24 and 48 h after surgery were -7.2 mg (95%CI: -12.5 to -2.1, p < 0.001), -3.9 mg (95%CI: -11.9 to 4.7, p = 0.26), -0.6 mg (95%CI: (-12.7 to 12.7, p = 0.80), and -1.8 mg (95%CI: (-11.6 to 15.6, p = 0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point. Conclusion Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.

Resumo Justificativa A dor pós-operatória é uma grande preocupação quando o remifentanil é usado para anestesia intravenosa total devido à sua meia-vida ultracurta. Os opioides de ação mais longa, como o sufentanil, têm sido usados durante a indução de anestesia intravenosa total à base de remifentanil como um meio de superar essa deficiência. Porém, a eficácia e segurança de tal estratégia ainda precisam de evidências advindas de ensaios clínicos randômicos. Portanto, objetivamos avaliar a eficácia analgésica e a segurança pós-operatória de uma dose única de sufentanil administrada durante a indução de anestesia intravenosa total à base de remifentanil. Métodos Quarenta pacientes eletivamente agendados para cirurgia abdominal aberta foram randomizados para receber anestesia intravenosa total à base de remifentanil, com ou sem uma dose única de sufentanil, após a indução da anestesia. Avaliamos o consumo de morfina no pós-operatório, administrado através de uma bomba de analgesia controlada pelo paciente. Os escores de dor autorrelatados e a ocorrência de náusea, vômito, prurido, agitação, sonolência e depressão respiratória também foram avaliados até dois dias após a cirurgia. Resultados A diferença média entre os grupos sufentanil e controle em relação ao consumo de morfina em sala de recuperação pós-anestesia e após 12, 24 e 48 horas da cirurgia foi de -7,2 mg (IC 95%: -12,5 a -2,1, p < 0,001), -3,9 mg (IC 95%: -11,9 a 4,7, p = 0,26), -0,6 mg (IC 95%: (-12,7 a 12,7, p = 0,80) e -1,8 mg (IC 95%: -11,6 para 15,6, p = 0,94), respectivamente. Não houve diferença significativa tanto nos escores de dor autorrelatados, quanto na incidência de eventos adversos entre os grupos. Conclusão Nossos achados sugerem que a administração de sufentanil durante a indução de anestesia intravenosa total à base de remifentanil está associada à redução do consumo de opioides no pós-operatório imediato.

[Sufentanil during anesthetic induction of remifentanil-based total intravenous anesthesia: a randomized controlled trial]. / Sufentanil durante a indução da anestesia intravenosa total à base de remifentanil: ensaio clínico randômico.

BACKGROUND: Postoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half-life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil-based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil-based total intravenous anesthesia. METHODS: Forty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil-based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient-controlled analgesia pump. Self-reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery. RESULTS: The mean difference between the sufentanil and control groups regarding morphine consumption in the post-anesthetic care unit and at 12, 24 and 48h after surgery were -7.2mg (95%CI: -12.5 to -2.1, p<0.001), -3.9mg (95%CI: -11.9 to 4.7, p=0.26), -0.6mg (95%CI: (-12.7 to 12.7, p=0.80), and -1.8mg (95%CI: (-11.6 to 15.6, p=0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point. CONCLUSION: Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.

Missed opportunities in the way medical schools evaluate the ethical domain in clerkship rotations.

BACKGROUND: Several lines of evidence indicate that medical schools have been failing to adequately nurture empathy and the ethical dimension in their graduates, the lack of which may play a central role in the genesis of medical errors, itself a major source of avoidable deaths, incapacity and wasted resources. It has been widely proposed that medical schools should adopt evaluation strategies as a means to promote a culture of respectful relationships. However, it is not clear if evaluation strategies in medical schools have addressed key domains related to that aim, such as ethics, through the perspective of their students. Hence, we conducted a national survey of instruments used by Brazilian medical schools to assess clerkship rotations from the perspective of students, with a main focus on the ethical domain. METHODS: The authors invited 121 randomly selected institutions to participate in the study. Key informants answered a questionnaire about clerkship rotations and sent copies of any instrument used to assess the quality of clerkship rotations according to the students' perspectives. RESULTS: Twenty-six (53%) of 49 participating schools used an instrument to assess the quality of clerkship rotations according to the perspective of students. Just 13 (27%) schools had instruments containing at least one question encompassing the ethical domain. Only 2 (4%) schools asked students specifically about the occurrence of any negative experience concerning the ethical domain during rotations. Merely 1 (2%) school asked students about having witnessed patient mistreatment and none asked about mistreatment against students themselves. CONCLUSIONS: There are several missed opportunities in the way medical schools assess the quality of clerkship rotations regarding the ethical domain. Closing the gap between usual institutional discourses regarding ethics and how that dimension is assessed within clerkship rotations might represent an important step towards the improvement of medical education and healthcare systems.

Cross-Cultural Adaptation of the Physician Orders for Life-Sustaining Treatment Form to Brazil.

BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) paradigm is considered one of the most important strategies to respect patients' values at the end of life in the United States. The cross-cultural adaptation of POLST entailed several methodological considerations, which may be informative for international researchers who may also consider bringing POLST to their countries as a means to promote care at the end of life that is consistent with patients' preferences. OBJECTIVE: To report the methods and outcome of the cross-cultural adaptation of the POLST form to Brazil. DESIGN: Cross-cultural adaptation study. SETTING/SUBJECTS: Twenty physicians and 10 patients at a university hospital participated in the pilot tests. RESULTS: The cross-cultural adaptation process included choosing which existing POLST form(s) to use as a source, deciding the intended reading level, which healthcare professionals should be allowed to sign the form, and consultation with attorneys, bioethicists, and members of the National POLST Paradigm Task Force. Pilot tests occurred in two stages using different approaches. First, 20 physicians were trained about POLST and asked for any unclear aspects related to the form. Second, trained investigators completed POLST forms after engaging in advance care planning conversations with 10 hospitalized patients or patients' surrogates. CONCLUSIONS: This report provides a basis for future cross-cultural adaptations of POLST to other countries. The authors hope such new adaptations will broaden the possibilities of research using POLST and also may promote wider provision of care at the end of life that is consistent with patients' preferences.

Influenza among the elderly in the Americas: a consensus statement.

Influenza exacts a heavy burden on the elderly, a segment of the population that is estimated to experience rapid growth in the near future. In the past decade most developed and several developing countries have recommended influenza vaccination for those > 65 years of age. The World Health Organization (WHO) set a goal of 75% influenza vaccination coverage among the elderly by 2010, but it was not achieved. In 2011, the Technical Advisory Group at the Pan American Health Organization, Regional Office of WHO for the Americas, reiterated the influenza vaccine recommendation for older adults. Relatively little information has been compiled on the immunological aspect of aging or on reducing its impact, information particularly relevant for clinicians and gerontologist with firsthand experience confronting its effects. To fill this data gap, in 2012 the Americas Health Foundation (Washington, D.C., United States) and the nonprofit, Fighting Infectious Diseases in Emerging Countries (Miami, Florida, United States), convened a panel of Latin American clinicians and gerontologists with expertise in influenza to discuss key issues and develop a consensus statement. The major recommendations were to improve influenza surveillance throughout Latin America so that its impact can be quantified; and to conduct laboratory confirmation of influenza for all patients who have flu-like symptoms and are frail, immunosuppressed, have comorbidities, are respiratory compromised, or have been admitted to a hospital. The panel also noted that: since evidence for antivirals in the elderly is unclear, their use should be handled on a case-by-case basis; despite decreased immunological response, influenza vaccination in older adults is still crucial; indirect immunization strategies should be encouraged; and traditional infection control measures are essential in long-term care facilities.

Influenza among the elderly in the Americas: a consensus statement / La gripe en los ancianos de la Región de las Américas: una declaración de consenso

Influenza exacts a heavy burden on the elderly, a segment of the population that is estimated to experience rapid growth in the near future. In the past decade most developed and several developing countries have recommended influenza vaccination for those > 65 years of age. The World Health Organization (WHO) set a goal of 75% influenza vaccination coverage among the elderly by 2010, but it was not achieved. In 2011, the Technical Advisory Group at the Pan American Health Organization, Regional Office of WHO for the Americas, reiterated the influenza vaccine recommendation for older adults. Relatively little information has been compiled on the immunological aspect of aging or on reducing its impact, information particularly relevant for clinicians and gerontologist with firsthand experience confronting its effects. To fill this data gap, in 2012 the Americas Health Foundation (Washington, D.C., United States) and the nonprofit, Fighting Infectious Diseases in Emerging Countries (Miami, Florida, United States), convened a panel of Latin American clinicians and gerontologists with expertise in influenza to discuss key issues and develop a consensus statement. The major recommendations were to improve influenza surveillance throughout Latin America so that its impact can be quantified; and to conduct laboratory confirmation of influenza for all patients who have flu-like symptoms and are frail, immunosuppressed, have comorbidities, are respiratory compromised, or have been admitted to a hospital. The panel also noted that: since evidence for antivirals in the elderly is unclear, their use should be handled on a case-by-case basis; despite decreased immunological response, influenza vaccination in older adults is still crucial; indirect immunization strategies should be encouraged; and traditional infection control measures are essential in long-term care facilities.

La gripe representa una fuerte carga para los ancianos, un segmento de la población que, según los cálculos, experimentará un rápido crecimiento en un futuro próximo. En el último decenio, la mayor parte de los países desarrollados y varios países en desarrollo han recomendado la vacunación antigripal de las personas mayores de 65 años de edad. La Organización Mundial de la Salud (OMS) estableció la meta de una cobertura de vacunación antigripal de 75% de los ancianos para el año 2010, pero no se alcanzó. En el 2011, el Grupo Consultivo Técnico de la Organización Panamericana de la Salud, Oficina Regional de la OMS para la Región de las Américas, reiteró la recomendación de la vacunación antigripal de los adultos mayores. Se ha recabado relativamente poca información sobre los aspectos inmunológicos del envejecimiento o sobre cómo reducir su repercusión, información particularmente pertinente para médicos clínicos y gerontólogos que deben afrontar de primera mano sus efectos. Para salvar esta brecha en materia de datos, en el 2012, la Americas Health Foundation (Washington, D.C., Estados Unidos) y la Fighting Infectious Diseases in Emerging Countries (fundación sin ánimo de lucro para la lucha contra las enfermedades infecciosas en los países emergentes, con sede en Miami, Florida, Estados Unidos) convocaron un grupo de expertos, médicos clínicos y gerontólogos latinoamericanos con pericia en el tema de la gripe, con objeto de debatir aspectos clave y elaborar una declaración de consenso. Las principales recomendaciones fueron mejorar la vigilancia de la gripe en toda América Latina para que pudiera cuantificarse su repercusión; y llevar a cabo la confirmación de laboratorio en todos los pacientes con síntomas similares a los de la gripe debilitados, inmunodeprimidos, con comorbilidades, con compromiso respiratorio o que hubieran sido ingresados en un hospital. El grupo de expertos también señaló que, dado que no existen datos probatorios claros en relación con los antivíricos en los ancianos, su uso debe manejarse caso por caso; que, a pesar de la reducción de la respuesta inmunitaria, la vacunación antigripal en adultos mayores sigue siendo crucial; que se deben promover las estrategias de vacunación indirecta; y que, en los establecimientos de asistencia a largo plazo, las medidas tradicionales de control de las infecciones son esenciales.

Influenza among adults in Latin America, current status, and future directions: a consensus statement.

In Latin America, adult influenza is a serious disease that exacts a heavy burden in terms of morbidity, mortality, and cost. Although much has been written about the disease itself, relatively little information has been compiled on what could be done to reduce its impact across the region, particularly from the perspective of clinicians with first-hand experience in confronting its effects. To fill this data gap, in 2011, the Pan American Health and Education Foundation (PAHEF) and the U.S.-based nonprofit Fighting Infectious Diseases in Emerging Countries (FIDEC) organized a conference and convened a panel of Latin American scientist-clinicians with experience and expertise in adult influenza in the region tol) discuss the major issues related to the disease and 2) develop and produce a consensus statement summarizing its impact as well as current efforts to diagnose, prevent, and treat it. The consensus panel concluded a more concerted and better-coordinated effort was needed to reduce the adverse impact of seasonal influenza and future pandemics, including more surveillance, more active involvement by both governmental and nongovernmental organizations, and a much greater effort to vaccinate more adults, especially those at high risk of contracting the disease. In addition, a new approach for diagnosing influenza was recommended.