Carol Howe

Frailty and Technology: A Systematic Review of Gait Analysis in Those with Frailty

Background: New technologies for gait assessment are emerging and have provided new avenues for accurately measuring gait characteristics in home and clinic. However, potential meaningful clinical gait parameters beyond speed have received little attention in frailty research. Objective: To study gait characteristics in different frailty status groups for identifying the most useful parameters and assessment protocols for frailty diagnosis. Methods: We searched PubMed, Embase, PsycINFO, CINAHL, Web of Science, Cochrane Library, and Age Line. Articles were selected according to the following criteria: (1) population: individuals defined as frail, prefrail, or transitioning to frail, and (2) outcome measures: quantitative gait variables as obtained by biomechanical analysis. Effect sizes (d) were calculated for the ability of parameters to discriminate between different frailty status groups. Results: Eleven publications met inclusion criteria. Frailty definitions, gait protocols and parameters were inconsistent, which made comparison of outcomes difficult. Effect sizes were calculated only for the three studies which compared at least two different frailty status groups. Gait speed shows the highest effect size to discriminate between frailty subgroups, in particular during habitual walking (d = 0.76-6.17). Gait variability also discriminates between different frailty status groups in particular during fast walking. Prominent parameters related to prefrailty are reduced cadence (d = 1.43) and increased step width variability (d = 0.64), whereas frailty (vs. prefrail status) is characterized by reduced step length during habitual walking (d = 1.32) and increased double support during fast walking (d = 0.78). Interestingly, one study suggested that dual-task walking speed can be used to predict prospective frailty development. Conclusion: Gait characteristics in people with frailty are insufficiently analyzed in the literature and represent a major area for innovation. Despite the paucity of work, current results suggest that parameters beyond speed could be helpful in identifying different categories of frailty. Increased gait variability might reflect a multisystem reduction and may be useful in identifying frailty. In addition, a demanding task such as fast walking or adding a cognitive distractor might enhance the sensitivity and specificity of frailty risk prediction and classification, and is recommended for frailty assessment using gait analysis.

Ultrasound-guided peripheral venous access: a meta-analysis and systematic review

Objectives The objective of this study was to determine through a systematic review of the literature and meta-analysis whether success rates, time to cannulation, and number of punctures required for peripheral venous access are improved with ultrasound guidance compared with traditional techniques in patients with difficult peripheral venous access. Methods We conducted a systematic search of MEDLINE, Web of Science, The Cochrane Library, ClinicalTrials.gov, Cumulative Index to Nursing, and Allied Health Literature. Studies were included if they met the following criteria: patients of any age identified as having difficult peripheral venous access; real-time ultrasound guidance was used for peripheral venous cannulation; and inclusion of at least one of these outcomes (success rates, time to successful cannulation and number of punctures required). Results Seven studies were selected for final analysis. Ultrasound guidance improved success rates when compared with traditional techniques [pooled odds ratio (OR) 3.96; 95% confidence interval (95% CI) 1.75-8.94]. No significant difference between ultrasound-guided techniques and traditional techniques was detected for time to cannulation or number of punctures required. Conclusions In patients with difficult peripheral venous access, ultrasound guidance increased success rates of peripheral venous placement when compared with traditional techniques. However, ultrasound guidance had no effect on time to successful cannulation or number of punctures required for successful cannulation.

Intensity-Modulated Radiotherapy After Extrapleural Pneumonectomy in the Combined-Modality Treatment of Malignant Pleural Mesothelioma

Introduction: Local therapy is becoming increasingly important as a part of the definitive treatment for malignant pleural mesothelioma after extrapleural pneumonectomy (EPP) because of the emergence of trimodality therapy consisted of chemotherapy, EPP, and adjuvant radiotherapy. Herein, we explore the current evidence and indications for adjuvant intensity-modulated radiotherapy (IMRT), as well as how to further improve this technique and adapt new technology in the delivering adjuvant radiotherapy in the setting of trimodality therapy. Methods: A systematic review of relevant studies identified through PubMed, ISI Web of Knowledge (Web of Science), the Cochrane Library, and the National Guideline Clearinghouse search engines was performed. Results: Local control remains poor despite the inclusion of conventional adjuvant radiation therapy in trimodality therapy. This can be improved by the delivery of adjuvant IMRT. However, IMRT can be associated with severe pulmonary toxicity if the radiation dose to the remaining lung is not kept to a very low level. This is especially true when patients are receiving chemotherapy. New advances in technology can allow for lower doses to the contralateral lung, decreased treatment delivery time, and improved target dose coverage. Conclusion: Excellent local control can be achieved through adjuvant IMRT after EPP for malignant pleural mesothelioma. Severe pulmonary toxicity may be avoided by setting stringent dose constraints for the contralateral lung. This can be aided by the advances in technology. Post-treatment surveillance may be reliably conducted by periodical [18F]-fluorodeoxyglucose-positron emission tomography imaging.

Medical Decision-Making for Older Adults without Family

Each year in the United States, individuals who lack decision‐making capacity because of acute or chronic cognitive impairment are in situations in which important medical decisions must be made for them, but tens of thousands of these individuals have no known family members or designated surrogates available to help with those decisions. Such individuals constitute 16% of patients in intensive care units, 3% of nursing home residents, and a large but unspecified number of individuals in a variety of settings who are facing end‐of‐life decisions. Several approaches are currently used to aid in medical decision‐making for people without families or designated surrogates, including hospital ethics committees, court‐appointed surrogate agents, reliance on advance directives if they are available, and even the use of computer‐based decision systems. These approaches all have limitations and often result in individuals receiving care that would not have been their preference. Additionally, because clinical care teams must wrestle with uncertainty about best approaches to care, lengths of hospital stay for individuals without family are longer, resulting in higher healthcare costs and potentially more‐aggressive interventions than individuals with family experience. This article reviews medical decision‐making for older adults without families or designated surrogates and proposes a solution: “health fiduciaries”—a new type of professional trained and certified to act as a surrogate decision‐maker for individuals who are unable to make decisions for themselves.

Benefit of statin pretreatment in prevention of contrast-induced nephropathy in different adult patient population: systematic review and meta-analysis

Objective Previous studies have suggested that statin pretreatment prevents contrast-induced nephropathy (CIN). However, single randomised trials are limited in their number of patients. This meta-analysis aims to assess the role of statin use in CIN prevention, as well as to determine patient subgroups that will benefit from statin pre-treatment. Methodology We searched PubMed, EMBASE, Web of science and the Cochrane Central Register of Controlled Trials databases for randomised controlled trials (RCT) comparing statin pretreatment versus placebo for preventing CIN. Our main outcome was the risk of CIN within 1–5 days after contrast administration. Results Data analysed from nine randomised studies with a total of 5143 patients, where 2559 received statins and 2584 received placebo, showed that statin pretreatment was associated with significant reduction in risk of CIN (MH-RR=0.47, 95% CI 0.34 to 0.64, Z=4.49, p<0.00001). This beneficial effect of statin was also seen in patients with baseline renal impairment (MH-RR=0.46, 95% CI 0.29 to 0.72, p=0.0008) and also those who were cotreated with NAC (MH-RR=0.46, 95% CI 0.25 to 0.83, p=0.01). Conclusions Statin pretreatment leads to significant reduction in CIN, and should be strongly considered in all patients who are planned for diagnostic and interventional procedures involving contrast-media administration.

Advance Directives for Older Adults in the Emergency Department: A Systematic Review

BACKGROUND It has been more than two decades since the passage of the Patient Self-Determination Act (PSDA) of 1991, an act that requires many medical points of care, including emergency departments (EDs), to provide information to patients about advance directives (ADs). OBJECTIVE The study objective was to determine the prevalence of ADs among ED patients with a focus on older adults and factors associated with rates of completion. METHODS We searched PubMed, Embase, PsycINFO, CINAHL, Web of Science, Medline, and the Cochrane Library. Articles were selected according to the following criteria: (1) population: adult ED patients; (2) outcome measures: quantitative prevalence data pertaining to ADs and factors associated with completion of an AD; (3) location: EDs in the United States; and (4) date: published 1991 or later. RESULTS Of the 258 references retrieved as a result of our search, six studies met inclusion criteria. Rates of patient-reported AD completion ranged from 21% to 53%, while ADs were available to ED personnel for 1% to 44% of patients. Patients aged ≥65 years had ADs 21% to 46% of the time. Sociodemographics (e.g., older age, specific religion, white or African American race, being widowed, or having children) and health status related variables (e.g., poor health, institutionalization, and having a primary care provider) were associated with greater likelihood of having an AD. CONCLUSIONS Published rates of AD completion vary widely among patients presenting to U.S. EDs. Patient sociodemographic and health status factors are associated with increased rates of AD completion, though rates are low for all populations.

Regulation of Cardiac Autonomic Nervous System Control across Frailty Statuses: A Systematic Review

Background: Frailty is a geriatric syndrome that leads to impairment in interrelated physiological systems and progressive homeostatic dysregulation in physiological systems. Objective: The focus of the present systematic review was to study the association between the activity of the cardiac autonomic nervous system (ANS) and frailty. Methods: A systematic literature search was conducted in multiple databases: PubMed/MEDLINE, Embase, Cochrane Library, Web of Science, CINAHL, and ClinicalTrials.gov; the last search was performed in March 2015. Inclusion criteria were: (1) that the studied population was classified for frailty according to a standard definition, such as Frieds criteria; (2) that the study had a nonfrail control group, and (3) that heart rate (HR) and/or heart rate variability (HRV) were parameters of interest in the study. Results: Of the 1,544 articles screened, 54 were selected for full-text review and 6 studies met the inclusion criteria. Assessment of HRV using different standard time domain, frequency domain, and nonlinear domain approaches confirmed the presence of an impaired cardiac ANS function in frail compared to nonfrail participants. Furthermore, HR changes while performing a clinical test (e.g., the seated step test or the lying-to-standing orthostatic test) were decreased in the frail group compared to the nonfrail group. Conclusions: The current systematic review provides evidence that the cardiac ANS is impaired in frail compared to nonfrail older adults, as indicated by a reduction in the complexity of HR dynamics, reduced HRV, and reduced HR changes in response to daily activities. Four out of 6 included articles recruited only female participants, and in the other 2 articles the effect of gender on impairment of cardiac ANS was insufficiently investigated. Therefore, further studies are required to study the association between cardiac ANS impairments and frailty in males. Furthermore, HRV was studied only during static postures such as sitting, or without considering the level of activity as a potential confounder. Accordingly, simultaneous measurement of both physiological (i.e., HRV) and kinematic (e.g., using wearable sensor technology) information may provide a better understanding of cardiac ANS impairments with frailty while controlling for activity.

Lifestyle behavior interventions delivered using technology in childhood, adolescent, and young adult cancer survivors: A systematic review.

Childhood, adolescent, and young adult cancer survivors demonstrate increased cardio‐metabolic risk factors, which are amenable to lifestyle changes. The use of technology to impact lifestyle change expands previously limited intervention access, yet little is known about its use. We summarized lifestyle interventions for survivors delivered using technology, finding six studies, primarily targeting physical activity. Study samples were small and durations ranged from 5 to 16 weeks and outcomes modest. Participants were older, white, survivors of leukemia or brain tumors, and the majority received Web‐based interventions. Study quality was moderate. Few technology‐based interventions have been developed, suggesting an area of opportunity for survivors.

Gait behaviors as an objective surgical outcome in low back disorders: A systematic review

BACKGROUND Objective motor performance measures, especially gait assessment, could improve evaluation of low back disorder surgeries. However, no study has compared the relative effectiveness of gait parameters for assessing motor performance in low back disorders after surgery. The purpose of the current review was to determine the sensitive gait parameters that address physical improvements in each specific spinal disorder after surgical intervention. METHODS Articles were searched with the following inclusion criteria: 1) population studied consisted of individuals with low back disorders requiring surgery; 2) low back disorder was measured objectively using gait assessment tests pre- and post-surgery. The quality of the selected studies was assessed using Delphi consensus, and meta-analysis was performed to compare pre- and post-surgical changes. FINDINGS Thirteen articles met inclusion criteria, which, almost exclusively, addressed two types of spinal disorders/interventions: 1) scoliosis/spinal fusion; and 2) stenosis/decompression. For patients with scoliosis, improvements in hip and shoulder motion (effect size=0.32-1.58), energy expenditure (effect size=0.59-1.18), and activity symmetry of upper-body muscles during gait were present after spinal fusion. For patients with spinal stenosis, increases in gait speed, stride length, cadence, symmetry, walking smoothness, and walking endurance (effect size=0.60-2.50), and decrease in gait variability (effect size=1.45) were observed after decompression surgery. INTERPRETATION For patients with scoliosis, gait improvements can be better assessed by measuring upper-body motion and EMG rather than the lower extremities. For patients with spinal stenosis, motor performance improvements can be captured by measuring walking spatio-temporal parameters, gait patterns, and walking endurance.

Dosimetric selection for helical tomotherapy based stereotactic ablative radiotherapy for early-stage non-small cell lung cancer or lung metastases.

Background No selection criteria for helical tomotherapy (HT) based stereotactic ablative radiotherapy (SABR) to treat early stage non-small cell lung cancer (NSCLC) or solitary lung metastases has been established. In this study, we investigate the dosimetric selection criteria for HT based SABR delivering 70 Gy in 10 fractions to avoid severe toxicity in the treatment of centrally located lesions when adequate target dose coverage is desired. Materials and Methods 78 HT-SABR plans for solitary lung lesions were created to prescribe 70 Gy in 10 fractions to the planning target volume (PTV). The PTV was set to have ≥95% PTV receiving 70 Gy in each case. The cases for which dose constraints for ≥1 OAR could not be met without compromising the target dose coverage were compared with cases for which all target and OAR dose constraints were met. Results There were 23 central lesions for which OAR dose constraints could not be met without compromising PTV dose coverage. Comparing to cases for which optimal HT-based SABR plans were generated, they were associated with larger tumor size (5.72±1.96 cm vs. 3.74±1.49 cm, p<0.0001), higher lung dose, increased number of immediately adjacent OARs ( 3.45±1.34 vs. 1.66±0.81, p<0.0001), and shorter distance to the closest OARs (GTV: 0.26±0.22 cm vs. 0.88±0.54 cm, p<0.0001; PTV 0.19±0.18 cm vs. 0.48±0.36 cm, p = 0.0001). Conclusion Delivery of 70 Gy in 10 fractions with HT to meet all the given OAR and PTV dose constraints are most likely when the following parameters are met: lung lesions ≤3.78 cm (11.98 cc), ≤2 immediately adjacent OARs which are ≥0.45 cm from the gross lesion and ≥0.21 cm from the PTV.