Publications by authors named "Kathryn McCarthy"

68 Publications

Multiple House Occupancy is Associated with Mortality in Hospitalised Patients with Covid-19.

Eur J Public Health 2021 May 17. Epub 2021 May 17.

Institute of Applied Health Science, University of Aberdeen, Aberdeen Scotland.

Background: In response to the COVID-19 pandemic, many countries mandated staying at home to reduce transmission. This study examined the association between living arrangements (house occupancy numbers) and outcomes in COVID-19.

Methods: Study population was drawn from the COPE Study, a multicentre cohort study. House occupancy was defined as: living alone; living with one other person; living with multiple other people; or living in a nursing/residential home. Outcomes were time from admission to mortality and discharge (Cox regression), and Day-28 mortality (logistic regression), analyses were adjusted for key comorbidities and covariates including admission: age; sex, smoking; heart failure; admission CRP; COPD; eGFR, frailty and others.

Results: 1584 patients were included from 13 hospitals across UK and Italy: 676 (42.7%) were female, 907 (57.3%) were male, median age was 74 years (range: 19-101). At 28 days, 502 (31.7%) had died. Median admission CRP was 67, 82, 79.5 and 83mg/L for those living alone, with someone else, in a house of multiple occupancy and in a nursing/residential home, respectively. Compared to living alone, living with anyone was associated with increased mortality: within a couple (aHR 1.39, 95%CI 1.09-1.77, p = 0.007); living in a house of multiple occupancy (aHR=1.67, 95%CI 1.17-2.38, p = 0.005); and living in a residential home (aHR=1.36, 95%CI 1.03-1.80, p = 0.031).

Conclusion: For patients hospitalised with COVID-19, those living with one or more people had an increased association with mortality, they also exhibited higher CRP indicating increased disease severity suggesting they delayed seeking care.
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http://dx.doi.org/10.1093/eurpub/ckab085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8247274PMC
May 2021

FMALE score: Combining practical risk scales to improve preoperative predictive accuracy in emergency general surgery: A multi-centre prospective cohort study.

Am J Surg 2021 Apr 27. Epub 2021 Apr 27.

Department of Population Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XW, Wales, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.amjsurg.2021.04.009DOI Listing
April 2021

Materials Matter: An Exploration of Text Complexity and Its Effects on Middle School Readers' Comprehension Processing.

Lang Speech Hear Serv Sch 2021 04 30;52(2):702-716. Epub 2021 Mar 30.

Educational Psychology, Department of Learning Sciences, Georgia State University, Atlanta.

Purpose Complex features of science texts present idiosyncratic challenges for middle grade readers, especially in a post-Common Core educational world where students' learning is dependent on understanding informational text. The primary aim of this study was to explore how middle school readers process science texts and whether such comprehension processes differed due to features of complexity in two science texts. Method Thirty 7th grade students read two science texts with different profiles of text complexity in a think-aloud task. Think-aloud protocols were coded for six comprehension processes: connecting inferences, elaborative inferences, evaluative comments, metacognitive comments, and associations. We analyzed the quantity and type of comprehension processes generated across both texts in order to explore how features of text complexity contributed to the comprehension processes students produced while reading. Results Students made significantly more elaborative and connecting inferences when reading a text with deep cohesion, simple syntax, and concrete words, while students made more evaluative comments, paraphrases, and metacognitive comments when reading a text with referential cohesion, complex syntax, and abstract words. Conclusions The current study provides exploratory evidence for features of text complexity affecting the type of comprehension processes middle school readers generate while reading science texts. Accordingly, science classroom texts and materials can be evaluated for word, sentence, and passage features of text complexity in order to encourage deep level comprehension of middle school readers.
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http://dx.doi.org/10.1044/2021_LSHSS-20-00117DOI Listing
April 2021

Implementing the SNIS recommendations for neurointerventional emergent care in the setting of COVID-19: impact on stroke metrics and patient outcomes.

J Neurointerv Surg 2021 Mar 23. Epub 2021 Mar 23.

Injury Outcomes Network, Englewood, Colorado, USA

Background: It is not clear whether the COVID-19 pandemic and subsequent Society of Neurointerventional Surgery (SNIS) recommendations affected hospital stroke metrics.

Methods: This retrospective cohort study compared stroke patients admitted to a comprehensive stroke center during the COVID-19 pandemic April 1 2020 to June 30 2020 (COVID-19) to patients admitted April 1 2019 to June 30 2019. We examined stroke admission volume and acute stroke treatment use.

Results: There were 637 stroke admissions, 52% in 2019 and 48% during COVID-19, with similar median admissions per day (4 vs 3, P=0.21). The proportion of admissions by stroke type was comparable (ischemic, P=0.69; hemorrhagic, P=0.39; transient ischemic stroke, P=0.10). Acute stroke treatment was similar in 2019 to COVID-19: tPA prior to arrival (18% vs, 18%, P=0.89), tPA treatment on arrival (6% vs 7%, P=0.85), and endovascular therapy (endovascular therapy (ET), 22% vs 25%, P=0.54). The door to needle time was also similar, P=0.12, however, the median time from arrival to groin puncture was significantly longer during COVID-19 (38 vs 43 min, P=0.002). A significantly higher proportion of patients receiving ET were intubated during COVID-19 due to SNIS guideline implementation (45% vs 96%, P<0.0001). There were no differences by study period in discharge mRS, P=0.84 or TICI score, P=0.26.

Conclusions: The COVID-19 pandemic did not significantly affect stroke admission volume or acute stroke treatment utilization. Outcomes were not affected by implementing SNIS guidelines. Although there was a statistical increase in time to groin puncture for ET, it was not clinically meaningful. These results suggest hospitals managing patients efficiently can implement practices in response to COVID-19 without impacting outcomes.
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http://dx.doi.org/10.1136/neurintsurg-2021-017415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7992379PMC
March 2021

The role of C-reactive protein as a prognostic marker in COVID-19.

Int J Epidemiol 2021 05;50(2):420-429

Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Background: C-reactive protein (CRP) is a non-specific acute phase reactant elevated in infection or inflammation. Higher levels indicate more severe infection and have been used as an indicator of COVID-19 disease severity. However, the evidence for CRP as a prognostic marker is yet to be determined. The aim of this study is to examine the CRP response in patients hospitalized with COVID-19 and to determine the utility of CRP on admission for predicting inpatient mortality.

Methods: Data were collected between 27 February and 10 June 2020, incorporating two cohorts: the COPE (COVID-19 in Older People) study of 1564 adult patients with a diagnosis of COVID-19 admitted to 11 hospital sites (test cohort) and a later validation cohort of 271 patients. Admission CRP was investigated, and finite mixture models were fit to assess the likely underlying distribution. Further, different prognostic thresholds of CRP were analysed in a time-to-mortality Cox regression to determine a cut-off. Bootstrapping was used to compare model performance [Harrell's C statistic and Akaike information criterion (AIC)].

Results: The test and validation cohort distribution of CRP was not affected by age, and mixture models indicated a bimodal distribution. A threshold cut-off of CRP ≥40 mg/L performed well to predict mortality (and performed similarly to treating CRP as a linear variable).

Conclusions: The distributional characteristics of CRP indicated an optimal cut-off of ≥40 mg/L was associated with mortality. This threshold may assist clinicians in using CRP as an early trigger for enhanced observation, treatment decisions and advanced care planning.
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http://dx.doi.org/10.1093/ije/dyab012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7989395PMC
May 2021

Routine use of immunosuppressants is associated with mortality in hospitalised patients with COVID-19.

Ther Adv Drug Saf 2021 18;12:2042098620985690. Epub 2021 Feb 18.

Department of Geriatric Medicine, 3rd Floor Academic Centre, Llandough Hospital, Penlan Road, Penarth, CF64 2XX.

Background: Whilst there is literature on the impact of SARS viruses in the severely immunosuppressed, less is known about the link between routine immunosuppressant use and outcome in COVID-19. Consequently, guidelines on their use vary depending on specific patient populations.

Methods: The study population was drawn from the COPE Study (COVID-19 in Older People), a multicentre observational cohort study, across the UK and Italy. Data were collected between 27 February and 28 April 2020 by trained data-collectors and included all unselected consecutive admissions with COVID-19. Load (name/number of medications) and dosage of immunosuppressant were collected along with other covariate data. Primary outcome was time-to-mortality from the date of admission (or) date of diagnosis, if diagnosis was five or more days after admission. Secondary outcomes were Day-14 mortality and time-to-discharge. Data were analysed with mixed-effects, Cox proportional hazards and logistic regression models using non-users of immunosuppressants as the reference group.

Results: In total 1184 patients were eligible for inclusion. The median (IQR) age was 74 (62-83), 676 (57%) were male, and 299 (25.3%) died in hospital (total person follow-up 15,540 days). Most patients exhibited at least one comorbidity, and 113 (~10%) were on immunosuppressants. Any immunosuppressant use was associated with increased mortality: aHR 1.87, 95% CI: 1.30, 2.69 (time to mortality) and aOR 1.71, 95% CI: 1.01-2.88 (14-day mortality). There also appeared to be a dose-response relationship.

Conclusion: Despite possible indication bias, until further evidence emerges we recommend adhering to public health measures, a low threshold to seek medical advice and close monitoring of symptoms in those who take immunosuppressants routinely regardless of their indication. However, it should be noted that the inability to control for the underlying condition requiring immunosuppressants is a major limitation, and hence caution should be exercised in interpretation of the results.

Plain Language Summary: We do not have much information on how the COVID-19 virus affects patients who use immunosuppressants, drugs which inhibit or reduce the activity of the immune system. There are various conflicting views on whether immune-suppressing drugs are beneficial or detrimental in patients with the disease. This study collected data from 10 hospitals in the UK and one in Italy between February and April 2020 in order to identify any association between the regular use of immunosuppressant medicines and survival in patients who were admitted to hospital with COVID-19. 1184 patients were included in the study, and 10% of them were using immunosuppressants. Any immunosuppressant use was associated with increased risk of death, and the risk appeared to increase if the dose of the medicine was higher. We therefore recommend that patients who take immunosuppressant medicines routinely should carefully adhere to social distancing measures, and seek medical attention early during the COVID-19 pandemic.
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http://dx.doi.org/10.1177/2042098620985690DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897811PMC
February 2021

Alteration of Metabolic Conditions Impacts the Regulation of IGF-II/H19 Imprinting Status in Prostate Cancer.

Cancers (Basel) 2021 Feb 16;13(4). Epub 2021 Feb 16.

IGF & Metabolic Endocrinology Group, Translational Health Sciences, Bristol Medical School, Learning & Research Building, Southmead Hospital, Bristol BS10 5NB, UK.

Prostate cancer is the second major cause of male cancer deaths. Obesity, type 2 diabetes, and cancer risk are linked. Insulin-like growth factor II (IGF-II) is involved in numerous cellular events, including proliferation and survival. The IGF-II gene shares its locus with the lncRNA, H19. IGF-II/H19 was the first gene to be identified as being "imprinted"-where the paternal copy is not transcribed-a silencing phenomenon lost in many cancer types. We disrupted imprinting behaviour in vitro by altering metabolic conditions and quantified it using RFLP, qPCR and pyrosequencing; changes to peptide were measured using RIA. Prostate tissue samples were analysed using ddPCR, pyrosequencing and IHC. We compared with in silico data, provided by TGCA on the cBIO Portal. We observed disruption of imprinting behaviour, in vitro with a significant increase in IGF-II and a reciprocal decrease in H19 mRNA; the increased mRNA was not translated into peptides. In vivo, most specimens retained imprinting status apart from a small subset which showed reduced imprinting. A positive correlation was seen between IGF-II and H19 mRNA expression, which concurred with findings of larger Cancer Genome Atlas (TGCA) cohorts. This positive correlation did not affect IGF-II peptide. Our findings show that type 2 diabetes and/or obesity, can directly affect regulation growth factors involved in carcinogenesis, indirectly suggesting a modification of lifestyle habits may reduce cancer risk.
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http://dx.doi.org/10.3390/cancers13040825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920081PMC
February 2021

A guttural cough.

BMJ 2021 01 13;372:m4977. Epub 2021 Jan 13.

Department of Radiology, Southmead Hospital, Bristol, UK.

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http://dx.doi.org/10.1136/bmj.m4977DOI Listing
January 2021

Impact of Surgery on Older Patients Hospitalized With an Acute Abdomen: Findings From the Older Persons Surgical Outcome Collaborative.

Front Surg 2020 16;7:583653. Epub 2020 Nov 16.

Department of Geriatric Medicine, Cardiff University, Cardiff, United Kingdom.

The impact of surgery compared to non-surgical management of older general surgical patients is not well researched. We examined the association between management and adverse outcomes in a cohort of emergency general surgery patients aged > 65 years. This multi-center study included 727 patients (mean+/-SD, 77.1 ± 8.2 years, 54% female) admitted to five UK hospitals. Data were analyzed using multi-level crude and multivariable logistic regression. Outcomes were: mortality at Day 30 and 90, length of stay, and readmission within 30 days of discharge. Covariates assessed were management approach, age, sex, frailty, polypharmacy, anemia, and hypoalbuminemia. Approximately 25% of participants ( = 185) underwent emergency surgery. Frailty and albumin were associated with mortality at 30 (frailty OR = 3.52 [95% CI 1.66-7.49], albumin OR = 3.78 ([95% CI 1.53-9.31]), and 90 days post discharge (frailty OR = 3.20 [95% CI 1.86-5.51], albumin OR=3.25 [95% CI 1.70-6.19]) and readmission (frailty OR = 1.56 [95% CI (1.04-2.35)]). Surgically managed patients and frailty had increased odds of prolonged hospitalization (surgery OR = 5.69 [95% CI 3.67-8.80], frailty OR = 2.17 [95% CI 1.46-3.23]). We found the impact of surgery on length of hospitalization in older surgical patients is substantial. Whether early comprehensive geriatric assessment and post-op rehabilitation would improve this outcome require further evaluation.
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http://dx.doi.org/10.3389/fsurg.2020.583653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705344PMC
November 2020

Frailty and mortality in patients with COVID-19 - Authors' reply.

Lancet Public Health 2020 11;5(11):e582

Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

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http://dx.doi.org/10.1016/S2468-2667(20)30224-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588175PMC
November 2020

The influence of ACE inhibitors and ARBs on hospital length of stay and survival in people with COVID-19.

Int J Cardiol Heart Vasc 2020 Dec 15;31:100660. Epub 2020 Oct 15.

Cardiff University and Honorary Consultant Physician, Aneurin Bevan University Health Board, UK.

Objective: During the COVID-19 pandemic the continuation or cessation of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) has been contentious. Mechanisms have been proposed for both beneficial and detrimental effects. Recent studies have focused on mortality with no literature having examined length of hospital stay. The aim of this study was to determine the influence of ACEi and ARBs on COVID-19 mortality and length of hospital stay.

Methods: COPE (COVID-19 in Older People) is a multicenter observational study including adults of all ages admitted with either laboratory or clinically confirmed COVID-19. Routinely generated hospital data were collected. Primary outcome: mortality; secondary outcomes: Day-7 mortality and length of hospital stay. A mixed-effects multivariable Cox's proportional baseline hazards model and logistic equivalent were used.

Results: 1371 patients were included from eleven centres between 27th February to 25th April 2020. Median age was 74 years [IQR 61-83]. 28.6% of patients were taking an ACEi or ARB. There was no effect of ACEi or ARB on inpatient mortality (aHR = 0.85, 95%CI 0.65-1.11). For those prescribed an ACEi or ARB, hospital stay was significantly reduced (aHR = 1.25, 95%CI 1.02-1.54, p = 0.03) and in those with hypertension the effect was stronger (aHR = 1.39, 95%CI 1.09-1.77, p = 0.007).

Conclusions: Patients and clinicians can be reassured that prescription of an ACEi or ARB at the time of COVID-19 diagnosis is not harmful. The benefit of prescription of an ACEi or ARB in reducing hospital stay is a new finding.
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http://dx.doi.org/10.1016/j.ijcha.2020.100660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7561344PMC
December 2020

Study protocol for the COPE study: COVID-19 in Older PEople: the influence of frailty and multimorbidity on survival. A multicentre, European observational study.

BMJ Open 2020 09 29;10(9):e040569. Epub 2020 Sep 29.

Geriatric Medicine, Cardiff University, Cardiff, UK.

Introduction: This protocol describes an observational study which set out to assess whether frailty and/or multimorbidity correlates with short-term and medium-term outcomes in patients diagnosed with COVID-19 in a European, multicentre setting.

Methods And Analysis: Over a 3-month period we aim to recruit a minimum of 500 patients across 10 hospital sites, collecting baseline data including: patient demographics; presence of comorbidities; relevant blood tests on admission; prescription of ACE inhibitors/angiotensin receptor blockers/non-steroidal anti-inflammatory drugs/immunosuppressants; smoking status; Clinical Frailty Score (CFS); length of hospital stay; mortality and readmission. All patients receiving inpatient hospital care >18 years who receive a diagnosis of COVID-19 are eligible for inclusion. Long-term follow-up at 6 and 12 months is planned. This will assess frailty, quality of life and medical complications.Our primary analysis will be short-term and long-term mortality by CFS, adjusted for age (18-64, 65-80 and >80) and gender. We will carry out a secondary analysis of the primary outcome by including additional clinical mediators which are determined statistically important using a likelihood ratio test. All analyses will be presented as crude and adjusted HR and OR with associated 95% CIs and p values.

Ethics And Dissemination: This study has been registered, reviewed and approved by the following: Health Research Authority (20/HRA1898); Ethics Committee of Hospital Policlinico Modena, Italy (369/2020/OSS/AOUMO); Health and Care Research Permissions Service, Wales; and NHS Research Scotland Permissions Co-ordinating Centre, Scotland. All participating units obtained approval from their local Research and Development department consistent with the guidance from their relevant national organisation.Data will be reported as a whole cohort. This project will be submitted for presentation at a national or international surgical and geriatric conference. Manuscript(s) will be prepared following the close of the project.
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http://dx.doi.org/10.1136/bmjopen-2020-040569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526029PMC
September 2020

The Clinical Frailty Scale: Estimating the Prevalence of Frailty in Older Patients Hospitalised with COVID-19. The COPE Study.

Geriatrics (Basel) 2020 Sep 21;5(3). Epub 2020 Sep 21.

Division of Population Medicine, Aneurin Bevan UHB, Cardiff University, Cardiff CF14 4XN, UK.

Frailty assessed using Clinical Frailty Scale (CFS) is a good predictor of adverse clinical events including mortality in older people. CFS is also an essential criterion for determining ceilings of care in people with COVID-19. Our aims were to assess the prevalence of frailty in older patients hospitalised with COVID-19, their sex and age distribution, and the completion rate of the CFS tool in evaluating frailty. Data were collected from thirteen sites. CFS was assessed routinely at the time of admission to hospital and ranged from 1 (very fit) to 9 (terminally ill). The completion rate of the CFS was assessed. The presence of major comorbidities such as diabetes and cardiovascular disease was noted. A total of 1277 older patients with COVID-19, aged ≥ 65 (79.9 ± 8.1) years were included in the study, with 98.5% having fully completed CFS. The total prevalence of frailty (CFS ≥ 5) was 66.9%, being higher in women than men (75.2% vs. 59.4%, < 0.001). Frailty was found in 161 (44%) patients aged 65-74 years, 352 (69%) in 75-84 years, and 341 (85%) in ≥85 years groups, and increased across the age groups (<0.0001, test for trend). Conclusion: Frailty was prevalent in our cohort of older people admitted to hospital with COVID-19. This indicates that older people who are also frail, who go on to contract COVID-19 may have disease severity significant enough to warrant hospitalization. These data may help inform health care planners and targeted interventions and appropriate management for the frail older person.
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http://dx.doi.org/10.3390/geriatrics5030058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554723PMC
September 2020

Cutaneous Stomal Recurrence of Colorectal Cancer After Curative Rectal Cancer Surgery - A Case Report and Systematic Review.

In Vivo 2020 Sep-Oct;34(5):2193-2199

Department of Colorectal Surgery, North Bristol NHS Trust, Bristol, U.K.

Background/aim: Stomal metastases from a primary rectal adenocarcinoma are rare, therefore, clear guidelines on treatment options are limited. We performed a systematic review including a case report on this subject with the primary objective of identifying the total number of cases in the literature. The secondary objective was to assess median survival.

Materials And Methods: A 59-year-old woman presented to our institution with anal incontinence to mucus leakage. Flexible sigmoidoscopy identified a carpet adenoma from the dentate line to the rectosigmoid junction. An abdomino-perineal resection (APR) was performed using the transanal total mesorectal excision technique (TaTME). No adjuvant chemotherapy was offered. Twenty-one months following the operation a stomal recurrence was identified. Palliative radiotherapy was commenced and the patient is alive 6 months later with no visible recurrence at the site of the stoma. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.

Results: The systematic review identified 19 individual cases of either metachronous or true metastatic recurrence, including our own case. Median survival was 30 months in the 8 cases where further treatment was offered and accepted.

Conclusion: Stomal metastases or metachronous colorectal cancer is uncommon. The causes for this pattern of spread are not clear. Long-term survival from cutaneous recurrence is generally poor. For carefully selected patients, redo surgery is an option with satisfactory results.
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http://dx.doi.org/10.21873/invivo.12029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652478PMC
June 2021

Prior Routine Use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Important Outcomes in Hospitalised Patients with COVID-19.

J Clin Med 2020 Aug 10;9(8). Epub 2020 Aug 10.

Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, Scotland, UK.

Coronavirus disease 2019 (COVID-19) infection causes acute lung injury, resulting from aggressive inflammation initiated by viral replication. There has been much speculation about the potential role of non-steroidal inflammatory drugs (NSAIDs), which increase the expression of angiotensin-converting enzyme 2 (ACE2), a binding target for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to enter the host cell, which could lead to poorer outcomes in COVID-19 disease. The aim of this study was to examine the association between routine use of NSAIDs and outcomes in hospitalised patients with COVID-19. This was a multicentre, observational study, with data collected from adult patients with COVID-19 admitted to eight UK hospitals. Of 1222 patients eligible to be included, 54 (4.4%) were routinely prescribed NSAIDs prior to admission. Univariate results suggested a modest protective effect from the use of NSAIDs, but in the multivariable analysis, there was no association between prior NSAID use and time to mortality (adjusted HR (aHR) = 0.89, 95% CI 0.52-1.53, = 0.67) or length of stay (aHR 0.89, 95% CI 0.59-1.35, = 0.58). This study found no evidence that routine NSAID use was associated with higher COVID-19 mortality in hospitalised patients; therefore, patients should be advised to continue taking these medications until further evidence emerges. Our findings suggest that NSAID use might confer a modest benefit with regard to survival. However, as this finding was underpowered, further research is required.
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http://dx.doi.org/10.3390/jcm9082586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465199PMC
August 2020

The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study.

Lancet Public Health 2020 08 30;5(8):e444-e451. Epub 2020 Jun 30.

Department of Surgery and Care of the Elderly, Southmead Hospital, North Bristol NHS Trust, Bristol, UK. Electronic address:

Background: The COVID-19 pandemic has placed unprecedented strain on health-care systems. Frailty is being used in clinical decision making for patients with COVID-19, yet the prevalence and effect of frailty in people with COVID-19 is not known. In the COVID-19 in Older PEople (COPE) study we aimed to establish the prevalence of frailty in patients with COVID-19 who were admitted to hospital and investigate its association with mortality and duration of hospital stay.

Methods: This was an observational cohort study conducted at ten hospitals in the UK and one in Italy. All adults (≥18 years) admitted to participating hospitals with COVID-19 were included. Patients with incomplete hospital records were excluded. The study analysed routinely generated hospital data for patients with COVID-19. Frailty was assessed by specialist COVID-19 teams using the clinical frailty scale (CFS) and patients were grouped according to their score (1-2=fit; 3-4=vulnerable, but not frail; 5-6=initial signs of frailty but with some degree of independence; and 7-9=severe or very severe frailty). The primary outcome was in-hospital mortality (time from hospital admission to mortality and day-7 mortality).

Findings: Between Feb 27, and April 28, 2020, we enrolled 1564 patients with COVID-19. The median age was 74 years (IQR 61-83); 903 (57·7%) were men and 661 (42·3%) were women; 425 (27·2%) had died at data cutoff (April 28, 2020). 772 (49·4%) were classed as frail (CFS 5-8) and 27 (1·7%) were classed as terminally ill (CFS 9). Compared with CFS 1-2, the adjusted hazard ratios for time from hospital admission to death were 1·55 (95% CI 1·00-2·41) for CFS 3-4, 1·83 (1·15-2·91) for CFS 5-6, and 2·39 (1·50-3·81) for CFS 7-9, and adjusted odds ratios for day-7 mortality were 1·22 (95% CI 0·63-2·38) for CFS 3-4, 1·62 (0·81-3·26) for CFS 5-6, and 3·12 (1·56-6·24) for CFS 7-9.

Interpretation: In a large population of patients admitted to hospital with COVID-19, disease outcomes were better predicted by frailty than either age or comorbidity. Our results support the use of CFS to inform decision making about medical care in adult patients admitted to hospital with COVID-19.

Funding: None.
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http://dx.doi.org/10.1016/S2468-2667(20)30146-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326416PMC
August 2020

Special needs of frail people undergoing emergency laparotomy surgery.

Age Ageing 2020 07;49(4):540-543

North Bristol NHS Trust, Bristol, UK and Department of Population Medicine, Cardiff University, Cardiff, South Glamorgan.

There are now over 30 000 emergency laparotomies under taken in the UK every year, a figure that is increasing year on year. Over half of these people are aged over 70 years old. Frailty is commonly seen in this population and becomes increasingly common with age and is seen in over 50% of elderly emergency laparotomies in people aged over 85 years old. In older people who undergo surgery one third will have died within one year of surgery, a figure which is worse in frail individuals. For those that do survive, post-operative morbidity is worse and 30% of frail older people do not return to their own home. In the UK, the National Emergency Laparotomy Audit (NELA) is leading the way in providing the evidence base in this population group. Beyond collecting data on every Emergency Laparotomy undertaken in the UK, it is also key in driving improvement in care. Their most recent report highlights that only 23% of patients over 70 years received geriatric involvement following surgery. More encouragingly, the degree of multidisciplinary geriatric involvement seems to be increasing. In the research setting, well designed studies focusing on the older frail emergency laparotomy patient are underway. It is anticipated that these studies will better define outcomes following surgery, improving the communication and decision making between patients, relatives, carers and their surgical teams.
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http://dx.doi.org/10.1093/ageing/afaa058DOI Listing
July 2020

Decision-Making in COVID-19 and Frailty.

Geriatrics (Basel) 2020 May 6;5(2). Epub 2020 May 6.

Department of Surgery, Salford Royal NHS Foundation Trust, Stott Ln, Salford M6 8HD, UK.

We write in response to the COVID-19 pandemic and the important recognition of co-existing frailty [COVID-19 rapid guideline: critical care in adults; NICE NG159] [...].
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http://dx.doi.org/10.3390/geriatrics5020030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344473PMC
May 2020

Timing of Anticoagulation in Patients with Cerebral Venous Thrombosis Requiring Decompressive Surgery: Systematic Review of the Literature and Case Series.

World Neurosurg 2020 05 24;137:408-414. Epub 2020 Feb 24.

Department of Trauma Research, Swedish Medical Center, Englewood, Colorado, USA. Electronic address:

Objective: Cerebral venous thrombosis (CVT) is a rare type of stroke whose pathophysiology differs from arterial stroke. CVT is treated with systemic anticoagulant therapy even in the setting of intracerebral hemorrhage. Patients who do not respond adequately may require decompressive surgery. The study objective was to examine the timing of anticoagulation in patients with CVT who require decompressive surgery through systematic literature review and consecutive case series.

Methods: A review of the literature was performed through PubMed using key word search to identify case series and cohort studies examining timing of anticoagulation following decompressive surgery. Our case series included 4 patients who had decompressive surgery for hemorrhagic CVT between 1 January, 2015 and 31 December, 2016 at our comprehensive stroke center.

Results: The literature review summarizes 243 patients from 15 studies whose timing of anticoagulation varied. The review suggests anticoagulation can be safely resumed at 48 hours postoperatively based on larger series and as early as 12 hours in smaller series, especially when delivered as a half or prophylactic dose. In our case series, timing of anticoagulation varied slightly but was started or resumed within 38-44 hours postoperatively in 3 patients and was started at the time of decompressive surgery without interruption in 1 patient. No patient had worsening hemorrhage or new hemorrhage while 2 patients rethrombosed.

Conclusions: Despite the lack of high-quality studies, this systematic review of patients with CVT requiring decompressive surgery indicates that anticoagulation can be safely initiated or resumed around 24-48 hours postoperatively; our series supports the existing literature.
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http://dx.doi.org/10.1016/j.wneu.2020.02.084DOI Listing
May 2020

The Prevalence of Delirium in An Older Acute Surgical Population and Its Effect on Outcome.

Geriatrics (Basel) 2019 Oct 16;4(4). Epub 2019 Oct 16.

Department of Surgery, Royal Alexandra hospital Paisley, G12 9PF, UK.

Background: With an ageing population, an increasing number of older adults are admitted for assessment to acute surgical units. Older adults have specific factors that may influence outcomes, one of which is delirium (acute cognitive impairment).

Objectives: To establish the prevalence of delirium on admission in an older acute surgical population and its effect on mortality. Secondary outcomes investigated include hospital readmission and length of hospital stay.

Method: This observational multi-centre study investigated consecutive patients, ≥65 years, admitted to the acute surgical units of five UK hospitals during an eight-week period. On admission the Confusion Assessment Method (CAM) score was performed to detect delirium. The effect of delirium on important clinical outcomes was investigated using tests of association and logistic regression models.

Results: The cohort consisted of 411 patients with a mean age of 77.3 years (SD 8.1). The prevalence of admission delirium was 8.8% (95% CI 6.2-11.9%) and cognitive impairment was 70.3% (95% CI 65.6-74.7%). The delirious group were not more likely to die at 30 or 90 days (OR 1.1, 95% CI 0.2 to 5.1, = 0.67; OR 1.4, 95% CI 0.4 to 4.1. = 0.82) or to be readmitted within 30 days of discharge (OR 0.9, 95% CI 0.4 to 2.2, = 0.89). Length of hospital stay was significantly longer in the delirious group (median 8 vs. 5 days respectively, = 0.009).

Conclusion: Admission delirium occurs in just under 10% of older people admitted to acute surgical units, resulting in significantly longer hospital stays.
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http://dx.doi.org/10.3390/geriatrics4040057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960557PMC
October 2019

Decreased Odds for Vasospasm Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage after Transitioning from Neurosurgery Led Care to a Neurology Led Multidisciplinary Approach.

J Vasc Interv Neurol 2019 May;10(3):30-33

Trauma Research.

Introduction: The limited research on the management of aneurysmal subarachnoid hemorrhages (aSAHs) has not assessed the efficacy of neurology-led care. Our objective was to describe aSAH patients' outcomes after transitioning from a neurosurgery-led intensive care unit (ICU) to a neurology-led multidisciplinary care neurocritical care unit (NCCU). The study hypothesis was that the neurology-led multidisciplinary care would improve patient outcomes.

Methods: This was a retrospective cohort study. We included patients (≥ 18) with aSAHs from 1/16 to 8/16 (pregroup) and from 3/17 to 11/17 (postgroup). The pregroup care was led by a neurosurgeon. The postgroup care included a neurologist, a pulmonary intensivist, a neurocritical care clinical nurse specialist, a neurosurgeon, and euvolemia protocol. The primary outcome was trips to interventional radiology (IR) for vasospasm treatment. Univariate analyses and multivariable ordinal logistic regression were used.

Results: There were 99 patients included: 50 in the pregroup and 49 in the postgroup. On average, postgroup patients were 7 years older than the pregroup ( = 0.05); no other demographic or clinical characteristics significantly differed. The 62% higher number of trips to IR for vasospasm treatment, when compared to the pregroup, < 0.001.

Conclusions: In aSAH patients, the neurology-led multidisciplinary care in the NCCU decreased the odds of repeated procedures for vasospasm treatment. Neurology-led multidisciplinary care could be more cost-effective than the neurosurgical-led care.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6613482PMC
May 2019

Comparing Outcomes of Patients With Idiopathic Subarachnoid Hemorrhage by Stratifying Perimesencephalic Bleeding Patterns.

J Stroke Cerebrovasc Dis 2019 Sep 12;28(9):2407-2413. Epub 2019 Jul 12.

Department of Trauma Research, Swedish Medical Center, Englewood, CO. Electronic address:

Background: To determine the clinical outcomes of perimesencephalic subarachnoid hemorrhages based on the computed tomography (CT) bleeding patterns.

Methods: This retrospective cohort study included: (1) patients (≥18 years) admitted to a comprehensive stroke center (January 2015-May 2018), (2) with angiography-negative, nontraumatic subarachnoid hemorrhage in a perimesencephalic or diffuse bleeding pattern, and (3) had CT imaging performed in ≤ 72 hours of symptom onset. Patients were stratified by location of bleeding on CT: Peri-1: focal prepontine hemorrhage; Peri-2: prepontine with suprasellar cistern +/- intraventricular extension; and diffuse.

Results: Of the 39 patients included, 13 were Peri-1, 11 were Peri-2, and 15 were diffuse. The majority were male (n = 26), with a mean (standard deviation) age of 55.3 (11.3) years, who often presented with headache (n = 37) and nausea (n = 28). Overall, patients in Peri-1 were significantly less likely to have hydrocephalus compared to Peri-2 and dSAH (P= .003), and 4 patients required an external ventricular drain. Five patients developed symptomatic vasospasm. Patients in Peri-1, compared to Peri-2 and diffuse, had a significantly shorter median neuro critical care unit length of stay (LOS) and hospital LOS. Most patients (n = 35) had a discharge modified Rankin Score between 0 and 2 with no significant differences found between groups.

Conclusion: These data suggest that patients with the best clinical course were those in Peri-1, followed by Peri-2, and then diffuse. Because these patients often present with similar clinical signs, stratifying by hemorrhage pattern may help clinicians predict which patients with perimesencephalic subarachnoid hemorrhage develop complications.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.06.032DOI Listing
September 2019

Cognitive impairment is associated with mortality in older adults in the emergency surgical setting: Findings from the Older Persons Surgical Outcomes Collaboration (OPSOC): A prospective cohort study.

Surgery 2019 05 19;165(5):978-984. Epub 2018 Nov 19.

Institute of Applied Health Sciences, University of Aberdeen, UK.

Background: Cognitive impairment is prevalent in older surgical patients; however, the condition is greatly under-recognized, and outcomes associated with it are poorly understood.

Methods: This is a prospective multicenter cohort study of unselected consecutive older adults admitted to 5 emergency general surgical units across the United Kingdom participating in the Older Persons Surgical Outcomes Collaboration from 2013-2014. The effect of moderate cognitive impairment defined as ≤17, bottom quartile of Montreal Cognitive Assessment was examined using multivariate logistic regression models. Primary outcome measure was the relationship between a low Montreal Cognitive Assessment score (≤17) and mortality at 30 and 90 days. Secondary outcome measures included the association between having a low Montreal Cognitive Assessment and hospital length of stay.

Results: A total of 539 older patients admitted consecutively to 5 surgical units during the 2013 and 2014 study periods were included. The median age (interquartile range) was 76 years (70-82 years), the emergency operation rate was 13% (n = 72). The prevalence of cognitive impairment, using the traditional Montreal Cognitive Assessment cutoff score of ≤26, was 84.4% and, using the recently suggested cutoff score of ≤23, the prevalence was 61.0%. Multivariable analyses showed patients with a low Montreal Cognitive Assessment score (≤17) had a three-fold increase in 30-day mortality (adjusted odds ratio = 3.10; 95% confidence interval:1.19-8.11; P = .021) and an increased length of hospital stay (10 or more days; 1.80 [1.10-2.94; P = .02] and 14 or more days; 2.06 [1.17-3.61; P = .012]).

Conclusion: We recommend a routine cognitive assessment in an emergency surgical setting whenever feasible to help identify patients at risk of poor outcomes.
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http://dx.doi.org/10.1016/j.surg.2018.10.013DOI Listing
May 2019

The prevalence of frailty and its association with clinical outcomes in general surgery: a systematic review and meta-analysis.

Age Ageing 2018 11;47(6):793-800

Academic Unit of Elderly Care & Rehabilitation, University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, UK.

Objectives: to investigate the prevalence and impact of frailty for general surgical patients.

Research Design And Methods: we conducted a systematic review and meta-analysis. Studies published between 1 January 1980 and 31 August 2017 were searched from seven databases. Incidence of clinical outcomes (mortality at Days 30 and 90; readmission at Day 30, surgical complications and length of stay) were estimated by frailty subgroup (not-frail, pre-frail and frail).

Results: 2,281 participants from nine observational studies were included, 49.3% (1013/2055) were males. Mean age ranged from 61 to 77 years old. Eight studies provided outcome data and were quality assessed and of fair or good quality, and one study only provided an estimate of prevalence and was not quality assessed. The prevalence estimate ranged between 31.3 and 45.8% for pre-frailty, and 10.4 and 37.0% for frailty. After pooling, Day 30 mortality was 8% (95% CI: 4-12%; I2 = 0%) for frail compared to 1% for non-frail patients (95% CI: 0-2%; I2 = 75%). Due to heterogeneity the Day 90 mortality was not pooled. Readmission rates were lower in the non-frail groups but were not pooled. Complications for the frail patients were 24%, (95% CI: 20-31%; I2 = 92%), pre-frail subgroup 9% (95% CI: 5-14%; I2 = 82%) and non-frail 5% (95% CI: 3-7%; I2 = 70%). The mean length of stay in frail people was 9.6 days (95% CI: 6.2-12.9) and 6.4 days (4.9-7.9) non-frail.

Conclusions: frailty is associated with adverse post-operative outcomes in general surgery.
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http://dx.doi.org/10.1093/ageing/afy110DOI Listing
November 2018

The Epidemiology of Reversible Cerebral Vasoconstriction Syndrome in Patients at a Colorado Comprehensive Stroke Center.

J Vasc Interv Neurol 2018 Jun;10(1):32-38

Department of Trauma Research, Swedish Medical Center, Englewood, CO, USA.

Objective: Vasoactive substances, including marijuana, are known precipitating factors of reversible cerebral vasoconstriction syndrome (RCVS). Our objective was to describe the demographics, suspected etiology, and outcomes of RCVS patients, with specific interest in examining the subset of patients who used marijuana prior to the onset of RCVS.

Methods: We identified and described consecutive RCVS cases treated at a regional, high-volume Comprehensive Stroke Center in Colorado (2012-2015). Univariate analyses were performed to examine the associations between the characteristics and outcomes (stroke and discharge disposition) of the RCVS patients by precipitating factors. We compared patients who used marijuana to those who did not and patients who used marijuana to patients who used vasoactive substances aside from marijuana.

Results: Forty patients had RCVS. Sixteen (40%) cases were deemed idiopathic and 24 (60%) were secondary to a suspected trigger. Vasoactive substances were the most common suspected trigger ( = 18/24, 75%), 6 (33%) of which were marijuana. Approximately 80% of patients experienced an intracranial hemorrhage, 20% had an ischemic stroke, and yet 78% were discharged home. Patients with RCVS secondary to marijuana were more often male ( = 0.05) and younger ( = 0.02) compared to those who did not use marijuana; no differences were observed in the outcomes. These findings were consistent when examining marijuana versus other vasoactive substances.

Conclusion: This study suggests there are demographic differences between patients with RCVS triggered by marijuana compared to the typical RCVS patient. As more states legalize marijuana, medical conditions such as RCVS and their association with marijuana warrants further study and awareness.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5999310PMC
June 2018

Is anemia associated with cognitive impairment and delirium among older acute surgical patients?

Geriatr Gerontol Int 2018 Jul 1;18(7):1025-1030. Epub 2018 Mar 1.

Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Aim: The determinants of cognitive impairment and delirium during acute illness are poorly understood, despite being common among older people. Anemia is common in older people, and there is ongoing debate regarding the association between anemia, cognitive impairment and delirium, primarily in non-surgical patients.

Methods: Using data from the Older Persons Surgical Outcomes Collaboration 2013 and 2014 audit cycles, we examined the association between anemia and cognitive outcomes in patients aged ≥65 years admitted to five UK acute surgical units. On admission, the Confusion Assessment Method was carried out to detect delirium. Cognition was assessed using the Montreal Cognitive Assessment, and two levels of impairment were defined as Montreal Cognitive Assessment <26 and <20. Logistic regression models were constructed to examine these associations in all participants, and individuals aged ≥75 years only.

Results: A total of 653 patients, with a median age of 76.5 years (interquartile range 73.0-80.0 years) and 53% women, were included. Statistically significant associations were found between anemia and age; polypharmacy; hyperglycemia; and hypoalbuminemia. There was no association between anemia and cognitive impairment or delirium. The adjusted odds ratios of cognitive impairment were 0.95 (95% CI 0.56-1.61) and 1.00 (95% CI 0.61-1.64) for the Montreal Cognitive Assessment <26 and <20, respectively. The adjusted odds ratio of delirium was 1.00 (95% CI 0.48-2.10) in patients with anemia compared with those without. Similar results were observed for the ≥75 years age group.

Conclusions: There was no association between anemia and cognitive outcomes among older people in this acute surgical setting. Considering the retrospective nature of the study and possible lack of power, findings should be taken with caution. Geriatr Gerontol Int 2018; 18: 1025-1030.
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http://dx.doi.org/10.1111/ggi.13293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6099313PMC
July 2018

Cognitive impairment in older patients undergoing colorectal surgery.

Scott Med J 2018 Feb 22;63(1):11-15. Epub 2018 Feb 22.

2 North Bristol NHS Trust, Bristol, UK.

Background With increasing numbers of older people being referred for elective colorectal surgery, cognitive impairment is likely to be present and affect many aspects of the surgical pathway. This study is aimed to determine the prevalence of cognitive impairment and assess it against surgical outcomes. Methods The Montreal Cognitive Assessment (MoCA) was carried out in patients aged more than 65 years. We recorded demographic information. Data were collected on length of hospital stay, complications and 30-day mortality. Results There were 101 patients assessed, median age was 74 years (interquartile range = 68-80), 54 (53.5%) were women. In total, 58 people (57.4%) 'failed' the Montreal Cognitive Assessment test (score ≤ 25). There were two deaths (3.4%) within 30 days of surgery in the abnormal Montreal Cognitive Assessment group and none in the normal group. Twenty-nine (28.7%) people experienced a complication. The percentage of patients with complications was higher in the group with normal Montreal Cognitive Assessment (41.9%) than abnormal Montreal Cognitive Assessment (19.9%) ( p = 0.01) and the severity of those complications were greater (chi-squared for trend p = 0.01). The length of stay was longer in people with an abnormal Montreal Cognitive Assessment (mean 8.1 days vs. 5.8 days, p = 0.03). Conclusion Cognitive impairment was common, which has implications for informed consent. Cognitive impairment was associated with less postoperative complications but a longer length of hospital stay.
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http://dx.doi.org/10.1177/0036933017750988DOI Listing
February 2018

A systematic review and meta-analysis of factors for delirium in vascular surgical patients.

J Vasc Surg 2017 10;66(4):1269-1279.e9

Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom.

Background: Delirium is a common syndrome responsible for a large burden of morbidity and mortality. In surgical settings, research into risk factors for postoperative delirium has largely focused on elective orthopedic patients. We performed a systematic review and meta-analysis to evaluate the evidence surrounding risk factors for delirium in vascular surgical populations.

Methods: Two independent reviewers searched five databases (MEDLINE, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO) from January 1987 to December 2015. We included primary research studies for incident delirium that used validated delirium assessment tools in exclusively vascular surgical populations.

Results: We identified 16 studies (3817 patients) that met the inclusion criteria. There was substantial clinical heterogeneity in the populations included under a heading of "vascular surgery." Studies were high quality, with an average Newcastle-Ottawa Scale score of 6.9. Summary incidence of delirium was 23.4% (range, 4.8%-39%). Across all studies, 157 separate risk factors were examined. Ten of the included studies used multivariable models in their analysis of risk factors. Meta-analysis of risk factors with data from more than three studies identified the following factors as conferring an increased risk of delirium: American Society of Anesthesiologists score >2 (odds ratio [OR], 3.44), renal failure (OR, 2.09), previous stroke (OR, 1.87), history of neurologic comorbidity (OR, 1.57), and male sex (OR, 1.30). Delirious patients were older (mean difference [MD], +4.99 years), had lower preoperative hemoglobin levels (MD, -0.66 g/dL), and stayed longer in intensive care units (MD, +1.06 days).

Conclusions: Delirium is common in vascular surgery settings. Meta-analysis has identified significant risk factors relating to the patient, the presentation, and the pathway of care. Better understanding of these risk factors may help in prediction, prevention, and early identification of delirium.
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http://dx.doi.org/10.1016/j.jvs.2017.04.077DOI Listing
October 2017

Characterization of yogurts made with milk solids nonfat by rheological behavior and nuclear magnetic resonance spectroscopy.

J Food Drug Anal 2016 10 31;24(4):804-812. Epub 2016 May 31.

Department of Food Science and Technology, University of California, Davis, CA 95616, USA.

The effect of adding milk solids nonfat (MSNF) on the physical properties and microstructure of yogurts was investigated. The physical properties of fat free yogurt, fat free with MSNF yogurt, whole fat yogurt, and whole fat with MSNF yogurt were analyzed using shear viscosity, viscoelasticity, and texture analysis. The two yogurts with MSNF had higher consistency coefficient (K), storage modulus (G'), yield stress, and hardness. To gain insight into the multiphase system, nuclear magnetic resonance (NMR) and brightfield microscope images were acquired. The addition of MSNF significantly modified NMR relaxation time; T values were reduced significantly. Brightfield microscope images showed that the size of the protein network of the two yogurts with MSNF added was greater than that of the two yogurts without MSNF added. The microstructural information supported the physical information. The results showed that the increase in MSNF contributed positively to strengthening the physical/mechanical properties of yogurt.
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http://dx.doi.org/10.1016/j.jfda.2016.04.002DOI Listing
October 2016
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