OptiCogs: feasibility of a multicomponent intervention to rehabilitate people with cognitive impairment post-stroke

BACKGROUND

Stroke is a leading cause of death and disability worldwide. Despite the prevalence and associated burden of cognitive impairment post-stroke, there is uncertainty regarding optimal cognitive rehabilitation for people post-stroke. This study aimed to assess whether a multicomponent intervention, called OptiCogs, is feasible, acceptable, and safe for people with cognitive impairment post-stroke. A secondary aim was to explore changes in cognitive function, fatigue, quality of life, physical function, and occupational performance, from pre-intervention to post-intervention.

METHODS

A feasibility study was conducted where people post-stroke with cognitive impairment enrolled in a 6-week multicomponent intervention. The primary outcomes recorded included response rate, recruitment rate, retention rate, adherence to the intervention protocol, adverse events, and acceptability of the intervention to people post-stroke. Secondary outcomes included (i) change in cognitive functioning using the Addenbrooke's Cognitive Examination III, (ii) fatigue using the Fatigue Severity scale, (iii) quality of life using the Stroke Specific Quality of Life scale (iv) physical function using the patient-reported outcomes measurement information system, and (v) patient-reported occupational performance using the Canadian Occupational Performance Measure. The Consolidated Standards of Reporting Trials extension reporting guidelines were followed, for pilot and feasibility studies, to standardize the conduct and reporting of this study.

RESULTS

The response rate was 10.9%. Nine eligible participants were enrolled during the 4-month recruitment period, with eight participants completing the entire 6-week intervention, as well as the pre- and post-intervention outcome measures. There were no reported adverse events. Participants were satisfied with the intervention and found it acceptable overall. Results of the secondary outcomes were promising for cognitive function (ACE III, pre: 63.3 ± 23.9 to post: 69 ± 24.6), fatigue (FSS, pre: 52.5 ± 7.3 to post: 45.6 ± 7.2), quality of life (SSQoL, pre: 131.0 ± 26.3 to post: 169.9 ± 15.3), physical function (PROMIS-PF, pre: 15.5 ± 6.3 to post: 15.8 ± 5.3), and occupational performance (COPM performance, pre: 9.3 ± 2.3 to post: 22.9 ± 4.2) and COPM satisfaction, pre: 9.9 ± 2.1 to post: 22.7 ± 3.5).

CONCLUSION

Preliminary results suggest low-modest recruitment and high retention rates for the OptiCogs intervention. Changes in cognitive function, fatigue, quality of life, and self-reported occupational performance show improvement from pre- to post-intervention. These potential benefits require further testing in a larger pilot trial.

TRIAL REGISTRATION

NCT05414539.

1298 THE IMPACT OF ACUTE HEALTHCARE UTILISATION ON FUNCTIONAL DECLINE IN OLDER ADULTS OVER TIME: A POPULATION-BASED COHORT STUDY

Introduction

Acute healthcare use varies by age, with older adults the highest users of most acute healthcare services. International reports have highlighted increased use of Emergency Department (ED) services by older adults. Older adults who visit the ED may be admitted to hospital or discharged home and are vulnerable to adverse outcomes including cognitive decline, falls, readmission, mortality and hospital acquired limitations in activities of daily living. Using data from The Irish Longitudinal Study on Ageing (TILDA), the aim of this study was to investigate the impact of acute healthcare utilisation at baseline on subjective and objective measures of function at four-year follow-up in older adults.

Methods

This study represents a secondary analysis of a prospective cohort study where data from Wave 1 (baseline) and Wave 3 (four-year follow up) of TILDA were analysed in conjunction with a public and patient involvement group of older adults. Acute healthcare utilisation was defined as an ED visit with or without hospitalisation in the previous 12 months. Function was assessed objectively using Timed-Up-and Go (TUG) and grip strength and subjectively using self-report limitations in activities of daily living and instrumental activities of daily living.

Results

A total of 1516 participants met the study inclusion criteria. Mean age was 70.9 years (SD=4.6) and 48% were male. At baseline, 1280 participants reported no acute healthcare use. 118 indicated an ED visit but no hospitalisation in the previous twelve months and 118 reported both an ED visit and hospitalisation. Adjusting for all covariates, compared to those with no acute healthcare utilisation, those with an ED visit with no hospital admission had poorer TUG performance at follow up (β= 0.67, 95% CI: 0.34, 1.29, p=0.039).

Conclusion

The results of this study support a relationship between acute healthcare utilisation and functional decline assessed by TUG at follow-up.

267 WHAT IS THE IMPACT OF ACUTE HEALTHCARE UTILISATION ON FUNCTIONAL DECLINE IN OLDER ADULTS OVER TIME? A POPULATION-BASED COHORT STUDY

Background

Acute healthcare use varies by age, with older adults the highest users of most acute healthcare services. Using data from The Irish Longitudinal Study on Ageing (TILDA), the aim of this study was to investigate the impact of acute healthcare utilisation at baseline on subjective and objective measures of function at four-year follow-up in older adults.

Methods

This study represents a secondary analysis of a prospective cohort study where data from Wave 1 (baseline) and Wave 3 (four-year follow up) of TILDA were analysed in conjunction with a public and patient involvement group of older adults. Acute healthcare utilisation was defined as an Emergency Department (ED) visit with or without hospitalisation in the previous 12 months. Function was assessed objectively using Timed-Up-and Go (TUG) and grip strength and subjectively using self-report limitations in activities of daily living and instrumental activities of daily living. Linear regression was used to investigate the relationship between ED use at baseline and grip strength and TUG performance at Wave 3. Logistic regression was used to investigate the relationship between ED use at baseline and whether a participant had a disability in ADL and IADL, or not, at Wave 3.

Results

A total of 1516 participants met the study inclusion criteria. Mean age was 70.9 years (SD=4.6) and 48% were male. At baseline, 1280 participants reported no acute healthcare use. 118 indicated an ED visit but no hospitalisation in the previous twelve months and 118 reported both an ED visit and hospitalisation. Adjusting for all covariates, compared to those with no acute healthcare utilisation, those with an ED visit with no hospital admission had poorer TUG performance at follow up (β= 0.67, 95% CI: 0.34, 1.29, p=0.039).

Conclusion

The results of this study support a relationship between acute healthcare utilisation and functional decline assessed by TUG at follow-up.

265 A PHYSIOTHERAPY-LED TRANSITION TO HOME INTERVENTION FOR OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE: A PILOT FEASIBILITY RANDOMISED-CONTROLLED TRIAL

Background

Older adults frequently attend the Emergency Department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. A presentation to an ED can be viewed as an opportunity to assess those at risk of adverse outcomes and initiate a care plan in those deemed as ‘high risk'. Our aim was to evaluate the feasibility of a physiotherapy led integrated care intervention for older adults discharged from the ED (ED-PLUS).

Methods

Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (Trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation.

Results

29 participants were recruited, indicating 97% of our recruitment target. 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70-89% in the usual care and CGA-only groups.

Conclusion

High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for six-month outcomes.

Evaluation of the evidence for self-management post-stroke within clinical practice guidelines for people with stroke: A systematic review

Introduction

Self-management post-stroke is essential where healthcare systems are stretched and stroke prevalence remains high. Self-management is recommended in stroke guidelines however, the quality of guidelines can vary and the evidence underpinning recommendations is unclear. The objectives of this paper are to identify and appraise current stroke guidelines, synthesise self-management recommendations and assess the evidentiary basis of these recommendations.

Method

Stroke guidelines were retrieved from a search of four databases and stroke association websites in July 2021. Four independent reviewers assessed their quality using the Appraisal of Guidelines Research and Evaluation 2nd Edition instrument. Self-management recommendations were extracted by hand, evaluated, synthesised and the evidence underpinning them appraised using the Canadian Stroke Best Practice Recommendations framework.

Results

Eleven guidelines were included in this systematic review, all of excellent methodological quality overall. One hundred and sixty-one recommendations were extracted from these guidelines and grouped into ten principles of self-management. A quarter of the recommendations were underpinned by level A evidence, 32% level B and 43% level C.

Conclusion

Although current stroke guidelines are of high methodological quality, there are considerable inconsistencies in self-management recommendations within and between these guidelines, with varying strengths of underpinning evidence. This article identifies a need for universal consensus regarding evidence-based self-management post-stroke.

Exploring the perspectives of key stakeholders on the design and delivery of a cognitive rehabilitation intervention for people post-stroke

Purpose

Stroke is a leading cause of death and disability worldwide. Despite the prevalence and associated burden of post-stroke cognitive impairment, there is uncertainty regarding optimum interventions to improve cognitive function in people post-stroke. The aim of this study is to explore the perspectives of key stakeholders on the design and development of a multidisciplinary intervention to rehabilitate cognitive deficits in people post-stroke.

Materials and methods

Audio-recorded, semi-structured interviews were employed with people post-stroke, caregivers, healthcare professionals and academics. All transcribed interviews were exported to NVivo software and analysed using reflexive thematic analysis.

Results

Thirty interviews were conducted across stakeholder groups including people post-stroke (n = 10), caregivers (n = 5), healthcare professionals (n = 14) and academics (n = 1). Four themes relevant to the design and development of the intervention were identified (i) engagement in the intervention must be meaningful, (ii) the point of readiness to engage, (iii) a familiar but flexible setting is key (iv) pragmatics of intervention delivery.

Conclusions

These findings present new perspectives across stakeholder groups on the design and delivery of an intervention to rehabilitate cognitive deficits in people post-stroke. Taken together with existing quantitative evidence, these findings will inform the development of a feasibility trial, examining patient and process outcomes, to rehabilitate cognitive deficits post-stroke.

1075 THE EFFECTIVENESS OF INTERVENTIONS TO REDUCE ADVERSE OUTCOMES AMONG OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE

Background

Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED.

Method

Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and grey literature was searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed and an algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied to outcomes.

Results

Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate.

Conclusion

Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The evidence for the effectiveness of ED interventions for older adults is limited. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended.

Rehabilitation of Cognitive Deficits Poststroke: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Despite the prevalence of cognitive impairment poststroke, there is uncertainty regarding interventions to improve cognitive function poststroke. This systematic review and meta-analysis evaluate the effectiveness of rehabilitation interventions across multiple domains of cognitive function.

METHODS

Five databases were searched from inception to August 2019. Eligible studies included randomized controlled trials of rehabilitation interventions for people with stroke when compared with other active interventions or standard care where cognitive function was an outcome.

RESULTS

Sixty-four randomized controlled trials (n=4005 participants) were included. Multiple component interventions improved general cognitive functioning (MD, 1.56 [95% CI, 0.69-2.43]) and memory (standardized MD, 0.49 [95% CI, 0.27-0.72]) compared with standard care. Physical activity interventions improved neglect (MD, 13.99 [95% CI, 12.67-15.32]) and balance (MD, 2.97 [95% CI, 0.71-5.23]) compared with active controls. Noninvasive brain stimulation impacted neglect (MD, 20.79 [95% CI, 14.53-27.04) and functional status (MD, 14.02 [95% CI, 8.41-19.62]) compared with active controls. Neither cognitive rehabilitation (MD, 0.37 [95% CI, -0.94 to 1.69]) nor occupational-based interventions (MD, 0.45 [95% CI, -1.33 to 2.23]) had a significant effect on cognitive function compared with standard care.

CONCLUSIONS

There is some evidence to support multiple component interventions, physical activity interventions, and noninvasive brain stimulation improving cognitive function poststroke. Findings must be interpreted with caution given the overall moderate to high risk of bias, heterogeneity of interventions, and outcome measures across studies.

Abstract TP67: Rehabilitation Of Cognitive Deficits Post-stroke: Systematic Review And Meta-analysis Of Randomised Controlled Trials Of Non-pharmacological Interventions

Background and Purpose: Stroke is among the leading causes of death and disability worldwide. Despite the prevalence of cognitive impairment post-stroke, there is uncertainty regarding the optimal type of rehabilitation intervention to improve cognitive functioning in people post-stroke. This systematic review and meta-analysis evaluates the effectiveness of rehabilitation interventions across multiple domains of cognitive function, namely, memory, attention, executive function, perception, apraxia and neglect, as well as general cognitive functioning.

Methods: Five databases were searched from inception to August 2019. Eligible studies included randomised controlled trials (RCTs) of rehabilitation interventions for people with stroke when compared to other active interventions or standard care where cognitive function was an outcome.

Results: Sixty-four RCTs (n= 4,005 participants) were included. Multiple component interventions improved general cognitive functioning (MD:1.56, 95% CI 0.69 to 2.43) and memory (SMD:0.49, 95% CI 0.27 to 0.72) compared to standard care. Physical activity interventions improved neglect (MD:13.99, 95% CI 12.67 to 15.32) and balance (MD:2.97 to 95% CI 0.71, 5.23) compared to active controls. Non-invasive brain stimulation (NIBS) impacted neglect (MD:20.79, 95% CI 14.53 to 27.04) and function (MD:14.02, 95% CI 8.41 to 19.62) compared to active controls. Neither cognitive rehabilitation (MD:0.37, 95% CI -0.94 to 1.69) or occupational-based interventions (MD:0.45, 95% CI -1.33 to 2.23) had a significant effect on cognitive function compared to standard care.

Conclusion: The evidence regarding the effects of rehabilitation interventions for improving cognitive deficits post-stroke is uncertain. Finings must be considered in the context of moderate and high risk of bias across various methodological domains. There is some evidence to support multiple component interventions, physical activity interventions and NIBS protocols. However, findings must be interpreted with caution given the heterogeneity of interventions and outcome measures used across studies.

Exploring the perspectives of key stakeholders on the design and delivery of an intervention to rehabilitate people with cognitive deficits post-stroke

Background: Stroke is a leading cause of death and disability worldwide. Cognitive impairment is common post-stroke and can result in negative sequalae such as a lower quality of life, increased carer burden and increased healthcare costs. Despite the prevalence and associated burden of post-stroke cognitive impairment, there is uncertainty regarding the optimum intervention to improve cognitive function post-stroke. By exploring the perspectives of people post-stroke, carers and healthcare professionals on cognitive impairment, this qualitative study aims to inform the design and development of an intervention to rehabilitate cognitive impairment post-stroke. Methods: A qualitative descriptive approach will be applied, using semi-structured interviews with people post-stroke, carers and healthcare professionals. People post-stroke will be recruited via gatekeepers from a local stroke support group and Headway, a brain injury support service. Carers will be recruited via a gatekeeper from a local carers branch. Healthcare professionals will be recruited via gatekeepers from relevant neurological sites and via Twitter. The final number of participants recruited will be guided by information power. Data will be collectively analysed and synthesised using thematic analysis. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines will be used to standardize the conduct and reporting of the research. Conclusions: It is anticipated that exploring the perspectives of people post-stroke, carers and healthcare professionals on cognitive impairment post-stroke will inform the development of an evidence-based optimal intervention to rehabilitate cognitive deficits post-stroke. This study was granted ethical approval from the Faculty of Education and Health Sciences Research Ethics Committee at the University of Limerick. Study findings will be disseminated locally through presentations at stroke support groups, as well as internationally through academic conferences and peer-reviewed journals.

Longitudinal Associations Between Gait, Falls, and Disability in Community-Dwelling Older Adults With Type II Diabetes Mellitus: Findings From The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

Diabetes is associated with gait deficits, future falls, and disability; however, it is unclear if associations remain after controlling for relevant confounders. This study investigated (i) the effects of type II diabetes on spatiotemporal gait parameters in community-dwelling older adults and (ii) if diabetes status was independently associated with future falls and disability, after controlling for gait and other confounders.

METHOD

Baseline data were obtained from 2608 community-dwelling adults (≥60 years) participating in The Irish Longitudinal Study on Ageing (TILDA). Diabetes was identified from self-reported doctors' diagnosis, medications, and glycated hemoglobin levels. Gait characteristics were obtained during single- and dual-task walking using a GAITRite mat (n = 2560). Incident falls and disability were collected over 4 years follow-up (n = 2473). Associations between diabetes status and gait (cross-sectional) and falls and disability (longitudinal) were investigated using regression analysis, adjusting for medications, cardiovascular health, neuropsychological function, and fall-related factors.

RESULTS

Diabetes (prevalence = 9.1%) was cross-sectionally associated with shorter dual-task step length after adjusting for covariates (β = -1.59, 95% CI: -3.10, -0.08, p < .05). Diabetes was independently associated with increased risk of future instrumental activity of daily living (IADL) difficulty in those with no prior difficulty (incidence rate ratio [IRR] = 1.51, 95% CI: 1.08, 2.11, p < .05) although dual-task step length was an important confounder in all disability models. No independent associations between diabetes and falls were observed.

CONCLUSIONS

Diabetes was independently associated with shorter dual-task step length and increased risk of future IADL difficulty. Multidimensional interventions addressing poor health and function in those with diabetes may help reduce the risk of gait deficits and future disability.

Exploring the perspectives of people post-stroke, carers and healthcare professionals to inform the development of an intervention to improve cognitive impairment post-stroke

Background: Stroke is a leading cause of death and disability worldwide. Cognitive impairment is common post-stroke and can result in negative sequalae such as a lower quality of life, increased carer burden and increased healthcare costs. Despite the prevalence and associated burden of post-stroke cognitive impairment, there is uncertainty regarding the optimum intervention to improve cognitive function post-stroke. By exploring the perspectives of people post-stroke, carers and healthcare professionals on cognitive impairment, this qualitative study aims to inform the design and development of an intervention to rehabilitate cognitive impairment post-stroke. Methods: A qualitative descriptive approach will be applied, using semi-structured interviews with people post-stroke, carers and healthcare professionals. People post-stroke will be recruited via gatekeepers from a local stroke support group and Headway, a brain injury support service. Carers will be recruited via a gatekeeper from a local carers branch. Healthcare professionals will be recruited via gatekeepers from relevant neurological sites and via Twitter. The final number of participants recruited will be guided by information power. Data will be collectively analysed and synthesised using thematic analysis. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines will be used to standardize the conduct and reporting of the research. Conclusions: It is anticipated that exploring the perspectives of people post-stroke, carers and healthcare professionals on cognitive impairment post-stroke will inform the development of an evidence-based optimal intervention to rehabilitate cognitive deficits post-stroke. This study was granted ethical approval from the Faculty of Education and Health Sciences Research Ethics Committee at the University of Limerick. Study findings will be disseminated locally through presentations at stroke support groups, as well as internationally through academic conferences and peer-reviewed journals.

Exploring the beliefs and experiences of older Irish adults and family carers during the novel coronavirus (COVID-19) pandemic: A qualitative study protocol

Background: In December 2019 a novel human coronavirus (COVID-19) was identified in Wuhan, China (Wu et al, 2020). The virus subsequently spread to most countries worldwide and the World Health Organisation characterised the outbreak a pandemic on March 11 th 2020 (WHO, 2020a). Older age is associated with an increased risk of mortality in patients with COVID-19 (Chen et al., 2020). In March 2020, the Irish Government introduced 'cocooning' as a measure for those over 70 years of age to minimise interactions with others by not leaving their homes (Dept. of Health, 2020). The COVID-19 pandemic presents unique threats to the health and well-being of older adults. This study aims to explore the longitudinal experiences and beliefs of older adults during the COVID-19 pandemic. Findings will be important for tailoring supports, interventions and public health information for this population. Methods: A longitudinal exploratory qualitative study will be conducted using repeated semi-structured telephone interviews with a convenient sample of older adults recruited from participants of an older adult and family carer stakeholder panel for health services research established by the Ageing Research Centre (ARC) at the University of Limerick and through known older adult contacts of ARC academic members. Interviews will be audio recorded, transcribed and analysed using a reflexive approach to thematic analysis. Participants will have the opportunity to review and discuss preliminary analysis of the interview data and to co-write / design dissemination materials. Ethics and Dissemination: Ethical approval has been granted by the Faculty of Education and Health Sciences University of Limerick, Research Ethics Committee (2020_03_51_EHS (ER)). Findings will be disseminated through open access journal publications and distribution of lay summaries, a press release and an infographic to organisations of and for older people in Ireland, broadcast and print media.

Dynapaenic obesity and its association with health outcomes in older adult populations: protocol for a systematic review

INTRODUCTION

Two major global health challenges are the rapidly ageing population and the high prevalence of obesity in all age groups. Older adults are also susceptible to age-related loss of muscle strength, termed dynapaenia. The co-occurrence of both obesity and dynapaenia, termed dynapaenic obesity (DO), has been associated with poorer health outcomes and increased healthcare usage compared with either state alone. The purpose of this systematic review is to quantify the prevalence and incidence of DO in older adult populations, and to explore the association between DO and health outcomes, specifically chronic disease and multimorbidity, functional disability and healthcare usage.

METHODS AND ANALYSIS

Using the Meta-analyses Of Observational Studies in Epidemiology guidelines, we will conduct a systematic review of cross-sectional and longitudinal observational studies of older adults, which include measures of DO and specified outcomes. Detailed literature searches of will be conducted using six electronic databases: Excerpta Medica dataBASE (EMBASE), PubMed, MEDLINE, SCOPUS, ScienceDirect and Cumulative Index of Nursing and Allied Health Complete (CINAHL), including articles published from database inception until Febuary 2019. The reference lists of included articles will also be searched. Two independent reviewers will undertake a three-step screening and review process using the Population, Risk Factor, Outcome framework to define eligibility. The Newcastle Ottawa Scale for non-randomised studies will be used to assess risk of bias and to rate study quality. The findings will be synthesised in a narrative summary, and a meta-analysis will be conducted where appropriate.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. Findings from this research will be submitted for peer-reviewed publication in academic journals, and presented at relevant academic conferences.

PROSPERO REGISTRATION NUMBER

CRD42018112471.

Maternal educational inequalities in measured body mass index trajectories in three European countries

BACKGROUND

Social inequalities in the prevalence of childhood overweight and obesity are well-established, but less is known about when the social gradient first emerges and how it evolves across childhood and adolescence.

OBJECTIVE

This study examines maternal education differentials in children's body mass trajectories in infancy, childhood and adolescence using data from four contemporary European child cohorts.

METHODS

Prospective data on children's body mass index (BMI) were obtained from four cohort studies-Generation XXI (G21-Portugal), Growing Up in Ireland (GUI) infant and child cohorts, and the Millennium Cohort Study (MCS-UK)-involving a total sample of 41,399 children and 120,140 observations. Children's BMI trajectories were modelled by maternal education level using mixed-effect models.

RESULTS

Maternal educational inequalities in children's BMI were evident as early as three years of age. Children from lower maternal educational backgrounds were characterised by accelerated BMI growth, and the extent of the disparity was such that boys from primary-educated backgrounds measured 0.42 kg/m² (95% CI 0.24, 0.60) heavier at 7 years of age in G21, 0.90 kg/m² (95% CI 0.60, 1.19) heavier at 13 years of age in GUI and 0.75 kg/m² (95% CI 0.52, 0.97) heavier in MCS at 14 years of age. The corresponding figures for girls were 0.71 kg/m² (95% CI 0.50, 0.91), 1.31 kg/m² (95% CI 1.00, 1.62) and 0.76 kg/m² (95% CI 0.53, 1.00) in G21, GUI and MCS, respectively.

CONCLUSIONS

Maternal education is a strong predictor of BMI across European nations. Socio-economic differentials emerge early and widen across childhood, highlighting the need for early intervention.

Kidney Disease in Women is Associated with Disadvantaged Childhood Socioeconomic Position

BACKGROUND

Socioeconomic position (SEP) is an important determinant of health and it is dynamic across the entire lifespan. We sought to investigate the relationship between life-course SEP and chronic kidney disease (CKD) using 3 conceptual models: critical period, pathway and accumulation.

METHODS

Cross-sectional analysis of 4,996 participants from The Irish Longitudinal Study on Ageing, a nationally representative cohort of community-dwelling adults aged ≥50 years. We defined childhood and adulthood SEP according to father's and respondent's occupation respectively. SEP was categorised as high (reference), intermediate, low and never worked. CKD was defined as a glomerular filtration rate < 60 mL/min/1.73 m2 estimated from the combination of creatinine and cystatin C. We used logistic regression to estimate the age-adjusted association between SEP and CKD separately in men and women.

RESULTS

Low childhood SEP was strongly associated with CKD in women, after adjusting for adulthood SEP (OR 1.90 [95% CI 1.24-2.92]), supporting the critical period hypothesis. This association was not explained by traditional CKD risk factors. Women who experienced low childhood SEP and whose circumstances improved in adulthood also had increased odds of CKD, further supporting a critical period effect in childhood. There was comparatively less evidence in support of the pathway or accumulation models. We did not observe a statistically significant association between SEP and CKD in men.

CONCLUSIONS

Our findings suggest that women exposed to disadvantaged SEP in childhood represent an at-risk group in whom there may be opportunities for identification of CKD and facilitation of health-promoting behaviours from an early age.

Prevalence and correlates of diagnosed and undiagnosed type 2 diabetes mellitus and pre-diabetes in older adults: Findings from the Irish Longitudinal Study on Ageing (TILDA)

AIMS

The prevalence of type 2 diabetes and pre-diabetes has increased rapidly in recent decades and this trend will continue as the global population ages. This study investigates the prevalence of, and factors associated with, diagnosed and undiagnosed type 2 diabetes mellitus and pre-diabetes in older adults in Ireland.

METHODS

Cross-sectional data from 5377 men and women aged 50 and over from Wave 1 of the Irish Longitudinal Study on Ageing (TILDA) was analysed. Diagnosed diabetes was defined using self-reported doctors' diagnosis and medications data. Glycated haemoglobin (HbA1c) analysis was used to identify undiagnosed and pre-diabetes. Age and sex-specific prevalence estimates were generated. Logistic regression was used to investigate the association between diabetes classification and the demographic, health and lifestyle characteristics of the population.

RESULTS

The prevalence of diagnosed and undiagnosed type 2 diabetes was 8.6% (95% confidence interval (CI): 7.6-9.5%) and 0.9% (95% CI: 0.6-1.1%) respectively. Diabetes was more prevalent in men than women and increased with age. The prevalence of pre-diabetes was 5.5% (95% CI: 4.8-6.3%) and increased with age. Diabetes and pre-diabetes were independently associated with male sex, central obesity and a history of hypertension, while undiagnosed diabetes was associated with geographic location and medical costs cover.

CONCLUSION

Despite high rates of obesity and other undiagnosed health conditions, the prevalence of undiagnosed and pre-diabetes is relatively low in community-dwelling older adults in Ireland. Addressing lifestyle factors in this population may help to further reduce the prevalence of pre-diabetes and improve outcomes for those with a previous diagnosis.

Ultrasound measurement of subcutaneous adipose tissue thickness accurately predicts total and segmental body fat of young adults

This study evaluated the ability of ultrasound measurement of subcutaneous adiposity to accurately determine whole body and segmental body fat in young adults aged 18-29 years. Subcutaneous adipose tissue (SAT) thickness was measured by ultrasound at five body sites in 135 subjects (83 men, 52 women) and compared with the corresponding segmental fat mass measured by dual energy X-ray absorptiometry (DXA). Ultrasound measures of SAT thickness were strongly correlated to segmental fat mass and total percentage (%) body fat (r = 0.697-0.907, p < 0.01). Prediction equations generated using quantile regression found SAT thickness at the abdomen and thigh to accurately predict % body fat in men (standard error of the estimate, SEE = 1.9%, 95% limits of agreement (LoA); -3.6% to +3.8%) and SAT thickness at the abdomen and medial calf to accurately predict % body fat in women (SEE = 3.0%, LoA; -6.5% to +5.4%). These data indicate that ultrasound measurement of SAT thickness proportionally reflects segmental fat mass and accurately predicts % body fat in young adults.

Application of rumen microbial genome information to livestock systems in the postgenomic era

Sequencing the genomes of individual rumen microbes and determining the function of their encoded genes promises to transform our understanding of the microbiology of the rumen. The diversity and density of microbes in the rumen, and our inability to culture the majority of rumen microbes, limit current genome studies to only a small fraction of the microbes present in this environment. Nevertheless, genomes of fibre-degrading organisms are beginning to reveal a previously unexpected abundance of genes encoding glycosyl hydrolases and carbohydrate esterases, which could be used to enhance fibre digestion in the rumen. Additionally, genome sequencing of a rumen methanogen is identifying conserved genes within the methanogenic archaea that may serve as targets for their inhibition and therefore reduction of methane emissions from ruminants. The problem of rumen microbe culturability can be overcome by a new approach called metagenomics, in which microbial DNAs are extracted from rumen samples and sequenced independent of cultivation. In the future, sequencing individual genomes and metagenomic libraries is likely to capture much more of the microbial DNA in the rumen and, coupled with postgenomic studies on gene and protein expression, is likely to enhance our knowledge of the microbial component of ruminant digestion.

Prophage-like elements in bifidobacteria: insights from genomics, transcription, integration, distribution, and phylogenetic analysis

So far, there is only fragmentary and unconfirmed information on bacteriophages infecting the genus Bifidobacterium. In this report we analyzed three prophage-like elements that are present in the genomes of Bifidobacterium breve UCC 2003, Bifidobacterium longum NCC 2705, and Bifidobacterium longum DJO10A, designated Bbr-1, Bl-1, and Blj-1, respectively. These prophagelike elements exhibit homology with genes of double-stranded DNA bacteriophages spanning a broad phylogenetic range of host bacteria and are surprisingly closely related to bacteriophages infecting low-G+C bacteria. All three prophage-like elements are integrated in a tRNA(Met) gene, which appears to be reconstructed following phage integration. Analysis of the distribution of this integration site in many bifidobacterial species revealed that the attB sites are well conserved. The Blj-1 prophage is 36.9 kb long and was induced when a B. longum DJO10A culture was exposed to mitomycin C or hydrogen peroxide. The Bbr-1 prophage-like element appears to consist of a noninducible 28.5-kb chimeric DNA fragment composed of a composite mobile element inserted into prophage-like sequences, which do not appear to be widely distributed among B. breve strains. Northern blot analysis of the Bbr-1 prophage-like element showed that large parts of its genome are transcriptionally silent. Interestingly, a gene predicted to encode an extracellular beta-glucosidase carried within the Bbr-1 prophage-like element was shown to be transcribed.

Clinical management of pain in children with cancer: selected approaches and innovative strategies

More than 50% of children with cancer experience some type of cancer-related pain. Yet many children with cancer do not receive the benefit of current knowledge or innovative techniques in pain management. The authors review specific types of pain observed in children with cancer. The case studies are examples of clinical situations in which the child with cancer experiences pain. Each case study is followed by a discussion of appropriate pain management strategies. Approaches to pain management discussed in this article emphasize several of the new techniques that are now being used for pediatric cancer pain management.

Squamous cell carcinoma in southern and northern Australia

Squamous cell carcinoma (scc) of the skin was studied in two similar populations, one living in the temperate zone of Australia, the other living in the tropics. In the tropics, the patients were significantly younger, the man to woman ratio approached unity, and women had significantly more sccs on the legs. In the temperate zone, men had significantly more on the head and neck, but women had significantly more on the upper and lower limbs.

Familial occurrence of multiple nonmelanoma skin cancer

A survey of patients with histologically confirmed nonmelanoma skin cancer (NMSC) found 12 families in which several members developed skin cancers. The prevalence of NMSC in these families was far greater than in the normal population. The trait appeared to be dominantly inherited, and NMSC developed at an earlier age in succeeding generations, possibly because of a change in sun exposure habits.

Basal-cell carcinoma in temperate and tropical Australia

The clinical features of patients with basal-cell carcinoma (BCC) living in temperate and tropical Australia were studied. In the temperate zone the patients were considerably older on average, men outnumbered women and there were differences between the sexes in the site of the prevalent BCC. In the tropics the patients were significantly younger on average, the male-to-female ratio approached unity and there were no differences between the sexes with regard to the site of the BCC.

Skin cancers and HLA frequencies in renal transplant recipients

An association between HLA DR7 and the development of multiple non-melanoma skin cancer was detected in immunosuppressed patients in southern Australia. The relative risk was 2.6 which was lower than for immunocompetent patients with the same skin cancers. HLA frequencies of renal transplant recipients with multiple skin cancers were determined. The types HLA B27 and HLA Dr7 were found in significantly higher frequency, and there was no absence of HLA A11.

The changing face of skin cancer in Australia

A survey of patients with basal cell carcinomas (BCCs) revealed that major changes have occurred since the World War II. In the pre-World War II generations, men out-number women and most BCCs occur on the head and neck. Men had more BCCs on the ear and trunk, while women had more on the head and leg. In the post-World War II generation, women outnumbered men and most BCCs occurred on the trunk.