1. In the aged care home population, increasing calcium and protein intake to achieve recommended levels led to a lower rate of falls and fractures, and increased bone mineral density after 12 months.
Evidence Rating Level: 1 (Excellent)
Aged residents in institutionalised care have higher rates of chronic illness, bone fragility, and muscle mass loss that can contribute to falls and fractures: In fact, approximately 30% of hip fractures in the community stem from individuals in institutional care. Although there is scant evidence for antiresorptive therapy in elderly fracture prevention, intake of certain nutrients has been observed to be suboptimal. For instance, calcium intake in this population is below 700 mg daily (the recommended intake is 1300 mg/day), contributing to more bone resorption than bone formation, and protein intake has been observed to be below 1 g/kg body weight/day, which contributes to loss of muscle mass. Therefore, the current study aimed to evaluate the impact of supplementing the diets of care home residents who have normal Vitamin D levels, with more milk, yogurt, and cheese (foods with calcium and protein), to achieve recommended intake levels. This study randomized aged care facilities in Australia with menus that had fewer than 2 dairy food servings daily. The intervention group with 27 facilities increased their dairy daily servings from 2 to 3.5, whereas the control group with 29 facilities continued their usual menus. The results showed no difference in weight in the intervention group (0.3 kg, 95% CI -0.8-1.4 kg, p = 0.56), whereas the control group had a mean weight loss of 1.4 kg (95% CI 0.6-2.1, p < 0.001), with a 0.3 kg (95% CI -0.6-0.0, p = 0.03) decrease in lean muscle mass. Across 90,557 person months of follow-up, there were significantly fewer fractures and falls in the intervention group. The incidence of fractures was 3.7% in intervention and 5.2% in controls (hazard ratio 0.67, 95% IC 0.48-0.93, p = 0.02). For hip fractures specifically, significance was achieved at 5 months follow up: the incidence was 1.3% in intervention and 2.4% in controls (HR 0.54, 95% CI 0.35-0.83, p = 0.005). For falls, significance was achieved at 3 months follow-up: the incidence was 57% in intervention and 62% in controls (HR 0.89, 95% CI 0.78-0.98, p = 0.04). Additionally, after 12 months of follow-up, the bone mineral density (BMD) of the spine, distal radius, and distal tibia were significantly higher in the intervention, whereas the BMD of the femoral neck were the same between groups. Overall, this study demonstrates that achieving recommended levels of calcium and protein intake in the aged care home population can decrease the risk of falls and fractures, and increase bone mineral density.
1. A first-time hospital admission for acute urinary retention in individuals aged 50 and over was associated with higher incidence of urogenital, colorectal, and neurological cancer diagnosis, in the 3-12 months after the admission.
Evidence Rating Level: 2 (Good)
Acute urinary retention refers to a painful, sudden onset inability to void. There are numerous causes ranging including infectious, inflammatory, and neurological: In men, the most common cause is obstruction from benign prostatic hyperplasia. Although other cancers have been proposed to cause obstruction or interference with bladder and urethra contraction, there is limited evidence that they cause acute urinary retention. Therefore, the current retrospective study aimed to examine the risk of urogenital, colorectal, and neurological cancers, comparing patients presenting to the hospital for the first time with acute urinary retention. The study cohort consisted of all patients in Denmark with a first hospital admission of acute urinary retention from 1995 to 2017, aged 50 and over. The cancer rates for the general population in Denmark was also estimated from national health records. In total, there were 75,893 patients admitted for acute urinary retention, 82.6% of whom were men. Within 3 months of follow-up the results showed 218 excess prostate cancers (95% CI 214-221) per 1000 person years, with 3198 observed in the urinary retention cohort versus 93 expected from the general population estimate. As well, there were an excess 56 urinary tract cancers (95% CI 54-58), 24 genital cancers (95% CI 21-27), 12 colorectal cancers (95% CI 11-13), and 2 neurological cancers (95% CI 2-2), per 1000 person years after 3 months of follow-up. Beyond 3 months follow-up, the risk of genital, colorectal, and neurological cancers was not substantially different from the general population, whereas the for prostate and urinary tract cancers, the risk was not different after 1 year of follow-up. Overall, this study demonstrated that acute urinary retention could be a presenting sign of various forms of cancer, since diagnosis of cancer was more frequent than the general population in the 3 months following a hospital admission for urinary retention.
Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry
1. A cluster analysis of European atrial fibrillation (AF) patients found that both cardiac and non-cardiac comorbidities were associated with a greater risk of adverse outcomes.
Evidence Rating Level: 2 (Good)
Atrial Fibrillation (AF) is a multifactorial condition associated with numerous risk factors and co-morbidities. These include cardiovascular (CV) comorbidities, such as heart failure, stroke, and coronary artery disease, as well as non-CV conditions, such as diabetes mellitus and chronic kidney disease. Due to the multitude of clinical phenotypes associated with AF, cluster analysis can be used to identify which phenotypes are at greater risk of adverse outcomes and mortality. This data analytics technique has been used in studying other CV conditions, but has seldom been applied to study AF. The current study is the largest observational non-industry of AF patients in Europe, known as the EORP-AF: Their aim involved identifying relevant multi-morbidity clinical phenotypes of AF, along with evaluating differences in clinical management, use of resources, and adverse outcomes. From the 9363 patients included in the analysis, three clusters were identified: Cluster 1 consisted of older patients with non-CV comorbidities (median [IQR] age of 73 [65-78] years), younger patients with few comorbidities (median [IQR] age 65 [56-72] years), and older patients with high prevalence of CV comorbidities and risk factors (median [IQR] age 73 [66-78] years). The study found that in terms of AF management, Cluster 3 had the highest use of antiplatelet drugs (p < 0.001), and oral anticoagulants (OACs) were lowest in Cluster 2 (p < 0.001). As well, a rate control strategy was more common in Cluster 2, whereas a rhythm control strategy was more common in Cluster 2 (p < 0.001). Within the mean [SD] length of hospital stay was lowest in Cluster 2 (4.36 [6.33] days), followed by Cluster 1 (6.52 [7.29] days), with the highest in Cluster 3 (8.07 [8.50] days), with differences between each cluster being significant (p < 0.001). In terms of adverse outcomes, such as CV events, all-cause death, and a composite score of the two, the lowest rate of events was found in Cluster 2, followed by Cluster 1 and 3 respectively. Compared to Cluster 2, the hazards ratio for the composite score was 2.09 in Cluster 1 (95% CI 1.74-2.51) and 2.79 in Cluster 3 (95% CI 2.32-3.35). Overall, this study demonstrated that the presence of comorbidities in older AF patients, whether CV or non-CV, were associated with a greater risk of adverse outcomes, compared to younger patients with few comorbidities.
1. Comparing statin and non statin using patients, there is no difference in rates of positive COVID-19 test result.
2. For patients under the age of 75, statin use is not associated with differences in emergency department visits, hospitalizations, and 30-day all-cause mortality following a positive test result.
3. For patients over 75, emergency department visits and hospitalizations were higher than in non-statin using patients, but 30-day all-cause mortality was lower.
Evidence Rating Level: 2 (Good)
Numerous chronic conditions, such as diabetes mellitus and chronic kidney disease, are not only risk factors for SARS-CoV-2 infection, but are also associated with worse outcomes. Although the association between COVID-19 morbidity and chronic medication use is unknown, a meta-analysis found that statin-using patients with COVID-19 infection had a 46% lower risk of death. However, a meta-analysis of statin treatment in patients with non-COVID-19 infections found no difference in 28-day hospital mortality. Therefore, the current observational study based in Alberta and Ontario, Canada, aimed to determine the association between statin use and COVID-19 infection rates, as well as morbidity and mortality. This involved identifying all adults with an RT-PCR swab test between January and June 2020. In total, there were 115,871 statin users and 353,878 statin nonusers identified, with statin users being more likely to test positive (3.6% versus 2.8%, p < 0.001), although this was not significant after adjusting for statin use by age. As well, for patients under the age of 75, statin users had a greater likelihood of visiting the emergency department (ED), being admitted to the ICU, or dying of any cause within 30 days of their positive result, although these differences were not significant after adjusting for patients’ propensity for statin use. For patients over 75, statin users were also more likely to visit the ED (28.2% versus 17.9%, adjusted odds ratio 1.41 [95% CI 1.23-1.61]) and be hospitalized (32.7% versus 21.9%, aOR 1.19 [95% CI 1.05-1.36]), but had lower all-cause mortality within 30 days of their positive result (26.9% versus 31.3%, aOR 0.76 [95% CI 0.67-0.86]). Overall, this study found that statin use did not worsen or improve outcomes for patients infected with COVID-19. In the over 75 population where statin use was associated with improved mortality, randomized controlled trials would be needed to further explore and substantiate this association.
1. Patients over 70 years old with Chronic kidney disease (CKD) had higher Short Physical Performance Battery (SPPB) scores after 6 months of intradialytic exercise therapy, compared to patients without exercise therapy.
Evidence Rating Level: 1 (Excellent)
As chronic kidney disease (CKD) progresses in a patient, physical function also declines, which in turn is associated with adverse events and mortality. Therefore, exercise therapy has been proposed as a potential intervention to improve physical function in patients going through dialysis. However, most studies have centred on a young to middle age population, with studies on the elderly being limited, despite facing unique barriers compared to younger age groups, such as cognitive slowing and physical disability. The current randomized controlled trial aimed to compare physical function decline in CKD hemodialysis patients of advanced age, with one group undergoing intradialytic exercise therapy, and the other group undergoing care as usual. There were 40 patients in the control group and 44 patients in the intervention. All were over 70 years old, and the intervention group underwent 6 months of supervised, individualized exercise therapy three times weekly, with each session conducted during the first 2 hours of hemodialysis. These sessions involved lower extremity exercises such as stretching, ergometer cycling, and resistance training. Three outcomes were measured: Lower extremity muscle strength (LES) which assess knee extensor strength, the Short Physical Performance Battery (SPPB) score which assesses balance, gait speed, and lower limb force (each with a score from 0 to 4 points), and the 10 metre walking speed. The study found no baseline differences between the groups, and no adverse events resulting from intradialytic exercise. There were no significant differences between groups for the LES (adjusted mean difference of 0.94, 95% CI -1.22-3.09, p = 0.64) and the 10 metre walking speed (adjusted mean difference of -0.02, 95% CI -0.15-0.12, p = 0.54). However, the intervention group had a higher SPPB score (adjusted mean difference 1.05, 95% CI 0.15-1.95, p = 0.01). Overall, this study demonstrated an improvement in physical function rom intradialytic exercise in advanced age CKD patients, specifically in the areas of balance, gait speed, and lower limb force.
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