BACKGROUND: Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear. OBJECTIVE: To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function. DESIGN: Prospective cohort study. SETTING: 241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019. SUBJECTS: Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2. METHODS: Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected. RESULTS: Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P 4): HR, 1.34 (95% CI, 1.18-1.51, P
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PURPOSE: Premorbid conditions affect prognosis of acutely-ill aged patients. Several lines of evidence suggest geriatric syndromes need to be assessed but little is known on their relative effect on the 30-day survival after ICU admission. The primary aim of this study was to describe the prevalence of frailty, cognition decline and activity of daily life in addition to the presence of comorbidity and polypharmacy and to assess their influence on 30-day survival.METHODS: Prospective cohort study with 242 ICUs from 22 countries. Patients 80 years or above acutely admitted over a six months period to an ICU between May 2018 and May 2019 were included. In addition to common patients' characteristics and disease severity, we collected information on specific geriatric syndromes as potential predictive factors for 30-day survival, frailty (Clinical Frailty scale) with a CFS > 4 defining frail patients, cognitive impairment (informant questionnaire on cognitive decline in the elderly (IQCODE) with IQCODE ≥ 3.5 defining cognitive decline, and disability (measured the activity of daily life with the Katz index) with ADL ≤ 4 defining disability. A Principal Component Analysis to identify co-linearity between geriatric syndromes was performed and from this a multivariable model was built with all geriatric information or only one: CFS, IQCODE or ADL. Akaike's information criterion across imputations was used to evaluate the goodness of fit of our models.RESULTS: We included 3920 patients with a median age of 84 years (IQR: 81-87), 53.3% males). 80% received at least one organ support. The median ICU length of stay was 3.88 days (IQR: 1.83-8). The ICU and 30-day survival were 72.5% and 61.2% respectively. The geriatric conditions were median (IQR): CFS: 4 (3-6); IQCODE: 3.19 (3-3.69); ADL: 6 (4-6); Comorbidity and Polypharmacy score (CPS): 10 (7-14). CFS, ADL and IQCODE were closely correlated. The multivariable analysis identified predictors of 1-month mortality (HR; 95% CI): Age (per 1 year increase): 1.02 (1.-1.03, p = 0.01), ICU admission diagnosis, sequential organ failure assessment score (SOFA) (per point): 1.15 (1.14-1.17, p < 0.0001) and CFS (per point): 1.1 (1.05-1.15, p < 0.001). CFS remained an independent factor after inclusion of life-sustaining treatment limitation in the model.CONCLUSION: We confirm that frailty assessment using the CFS is able to predict short-term mortality in elderly patients admitted to ICU. Other geriatric syndromes do not add improvement to the prediction model. Since CFS is easy to measure, it should be routinely collected for all elderly ICU patients in particular in connection to advance care plans, and should be used in decision making.
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Background: The Clinical Frailty Scale (CFS) is frequently used to measure frailty in critically ill adults. There is wide variation in the approach to analysing the relationship between the CFS score and mortality after admission to the ICU. This study aimed to evaluate the influence of modelling approach on the association between the CFS score and short-term mortality and quantify the prognostic value of frailty in this context. Methods: We analysed data from two multicentre prospective cohort studies which enrolled intensive care unit patients ≥ 80 years old in 26 countries. The primary outcome was mortality within 30-days from admission to the ICU. Logistic regression models for both ICU and 30-day mortality included the CFS score as either a categorical, continuous or dichotomous variable and were adjusted for patient’s age, sex, reason for admission to the ICU, and admission Sequential Organ Failure Assessment score. Results: The median age in the sample of 7487 consecutive patients was 84 years (IQR 81–87). The highest fraction of new prognostic information from frailty in the context of 30-day mortality was observed when the CFS score was treated as either a categorical variable using all original levels of frailty or a nonlinear continuous variable and was equal to 9% using these modelling approaches (p < 0.001). The relationship between the CFS score and mortality was nonlinear (p < 0.01). Conclusion: Knowledge about a patient’s frailty status adds a substantial amount of new prognostic information at the moment of admission to the ICU. Arbitrary simplification of the CFS score into fewer groups than originally intended leads to a loss of information and should be avoided.
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PURPOSE: To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU.METHODS: This prospective study included intensive care patients aged ≥ 80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up.RESULTS: LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32-7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78-2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12-1.34) and SOFA score [OR of 1.07 (95% CI 1.05-1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries.CONCLUSIONS: The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country.TRIAL REGISTRATION: ClinicalTrials.gov (ID: NTC03134807).
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Voor het meten van de mobiliteit bij geriatrische patiënten en bij patiënten met evenwichtsstoornissen is in 1986 door Mathias de Timed Up and Go test (TUG) ontwikkeld. Deze oorspronkelijk Engelstalige versie van de test werd in 2000 in het Nederlands vertaald door De Jong. Het meetinstrument is zowel evaluatief als inventariserend en wordt aanbevolen in de KNGF-richtlijnen ‘Osteoporose’, ‘Beroerte’ en ‘Ziekte van Parkinson’.
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The increasing demand for Prunus africana resources is an opportunity for its conservation and commercial use to support livelihoods in Africa. The objective for this study was to investigate major steps to advance production of P. africana for long-term commercial use in Uganda. Specific objectives were to explore potential production schemes, setbacks in production and strategies to advance it. The study was done by review of literature, documents and interviews with experts. Results indicated Agroforestry and large plantations to be useful schemes for production. Identified setbacks are: low trade in P. africana, unknown returns from production, competing land uses, long growth period, limited market assurance and information. The lack of a resource assessment for P. africana in forests contributes to its low trade which undermines related economic benefits for national development and incentives to commercial production. We propose that a national Quantitative resource assessment of P. africana in forests is one of the crucial steps that should be undertaken to carefully organise and advance sustainable trade to provide rational incentives for commercial production. Subsequently, production should be localised in suitable sites and producers be organised into cooperatives. Further research to improve returns from commercial production of P. africana is needed.
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INTRODUCTION: Sufficient high quality dietary protein intake is required to prevent or treat sarcopenia in elderly people. Therefore, the intake of specific protein sources as well as their timing of intake are important to improve dietary protein intake in elderly people.OBJECTIVES: to assess the consumption of protein sources as well as the distribution of protein sources over the day in community-dwelling, frail and institutionalized elderly people.METHODS: Habitual dietary intake was evaluated using 2- and 3-day food records collected from various studies involving 739 community-dwelling, 321 frail and 219 institutionalized elderly people.RESULTS: Daily protein intake averaged 71 ± 18 g/day in community-dwelling, 71 ± 20 g/day in frail and 58 ± 16 g/day in institutionalized elderly people and accounted for 16% ± 3%, 16% ± 3% and 17% ± 3% of their energy intake, respectively. Dietary protein intake ranged from 10 to 12 g at breakfast, 15 to 23 g at lunch and 24 to 31 g at dinner contributing together over 80% of daily protein intake. The majority of dietary protein consumed originated from animal sources (≥60%) with meat and dairy as dominant sources. Thus, 40% of the protein intake in community-dwelling, 37% in frail and 29% in institutionalized elderly originated from plant based protein sources with bread as the principle source. Plant based proteins contributed for >50% of protein intake at breakfast and between 34% and 37% at lunch, with bread as the main source. During dinner, >70% of the protein intake originated from animal protein, with meat as the dominant source.CONCLUSION: Daily protein intake in these older populations is mainly (>80%) provided by the three main meals, with most protein consumed during dinner. More than 60% of daily protein intake consumed is of animal origin, with plant based protein sources representing nearly 40% of total protein consumed. During dinner, >70% of the protein intake originated from animal protein, while during breakfast and lunch a large proportion of protein is derived from plant based protein sources.
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In the original publication Dr Patrick Meybohm of the Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Frankfurt University Hospital, Frankfurt, Germany was inadvertently omitted from the list of investigators.
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Internationalizing curricula. Needs and wishes of alumni and employers with regard to international competencies. Internationalization has become of great importance for universities acrossthe globe. The labour market is becoming international, with internationalopportunities and international competition. Emerging markets such as India, China and Russia are gaining economic power. Global challenges demand world-wide solutions. Production and marketing networks span the globe and various forms of migration have resulted in a large cultural diversity within nations. As a result, societies and labour markets are changing as well. In order to deal with these societal changes adequately and to succeed in today’s labour market, graduates need to be equipped with international competencies. In a survey among 500 chief executives, ICM Research (on behalf of Think Global and The British Council, 2011) showed that employers strongly value staff members who are able to work in an international and multicultural environment. Similar results were found in Diamond et al. (2011), in which ‘multicultural teamwork’ was considered most important. The Hague University of Applied Sciences seeks to prepare its students adequately for the world of tomorrow. The University’s development plans (e.g. HogeschoolOntwikkelingsPlan, HOP 7, 2009-2013 and HOP 8, 2014-2017) indicate that its vision is to train students to be globally-minded professionals with an international and multicultural perspective, who are world-citizens, interested in global issues and able to deal with diversity in a constructive manner. They are to be professionals, who possess the competencies to function well in an international and intercultural environment. Internationalization is therefore high on the agenda of The Hague University of Applied Sciences (THUAS) which is illustrated by the fact that, as of 2014, new students in all academies have to fill 12.5% (30 ECTS) of their four-year Bachelor program with international activities. These activities can range from an internship or semester abroad (student mobility) to participating in full programs of study or minors in which English is the medium of instruction, or an internationally themed minor (Internationalization at Home, IaH). And this is only the beginning. Internationalization is a means, not an end. All THUAS courses are looking into ways in which they can internationalize their curriculum. And in doing so, they need to be innovative (Leask, 2009) and keep in mind the specific needs and wishes of alumni and their employers with regard to international competences. The THUAS research group International Cooperation supports these internationalization policy objectives by investigating various aspects, such as: • The acquisition and development of international competencies among students. • The extent to which lecturers possess international competencies and what their needs and wishes are for further development. • The international competencies THUAS graduates have acquired as part of their degree and how THUAS has stimulated this development. • The international competencies that employers and alumni consider important. Although international competencies and employability have received growing attention in internationalization research, existing studies have mainly focused on: • The effects of study abroad on the development of international competence (cf. Hoven & Walenkamp, 2013). • The effects of an experience abroad (study, internship, voluntary work) on employability. • A more general analysis of the skills employers look for in prospective employees.
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BACKGROUND & AIMS: Diagnosed prevalence of malnutrition and dietary intake are currently unknown in patients with severe aortic stenosis planned to undergo Transcatheter Aortic Valve Implantation (TAVI). This study describes the preprocedural nutritional status, protein intake and diet quality.METHODS: Consecutive preprocedural TAVI patients were asked to participate in this explorative study. Nutritional status was diagnosed with the global leadership initiative on malnutrition (GLIM) criteria. Preprocedural protein intake and diet quality were assessed with a three-day dietary record. To increase the record's validity, a researcher visited the participants at their homes to confirm the record. Protein intake was reported as an average intake of three days and diet quality was assessed using the Dutch dietary guidelines (score range 0-14, 1 point for adherence to each guideline).RESULTS: Of the included patients (n = 50, median age 80 ± 5, 56% male) 32% (n = 16) were diagnosed with malnutrition. Patients diagnosed with malnutrition had a lower protein intake (1.02 ± 0.28 g/kg/day vs 0.87 ± 0.21 g/kg/day, p = 0.04). The difference in protein intake mainly took place during lunch (20 ± 13 g/kg vs 13 ± 7 g/kg, p = 0.03). Patients adhered to 6.4 ± 2.2 out of 14 dietary guidelines. Adherence to the guideline of whole grains and ratio of whole grains was lower in the group of patients with malnutrition than in patients with normal nutritional status (both 62% vs 19%, p = 0.01). In a multivariate analysis diabetes mellitus was found as an independent predictor of malnutrition.CONCLUSION: Prevalence of malnutrition among TAVI patients is very high up to 32%. Patients with malnutrition had lower protein and whole grain intake than patients with normal nutritional status. Furthermore, we found diabetes mellitus as independent predictor of malnutrition. Nutrition interventions in this older patient group are highly warranted.
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