A systematic review of perioperative clinical practice guidelines for care of older adults living with frailty

BACKGROUND

Perioperative frailty is prevalent and requires complex management, which could be guided by clinical practice guidelines (CPGs). The objective of this systematic review was to identify and synthesise CPGs that provide perioperative recommendations specific to older adults living with frailty.

METHODS

After protocol registration, we performed a systematic review of CPGs. MEDLINE, Embase, CINAHL, and 14 grey literature databases were searched (January 1, 2000 until December 22, 2021). We included all CPGs that contained at least one frailty-specific recommendation related to any phase of the perioperative period. We compiled all relevant recommendations, extracted underlying strength of evidence, and categorised them by perioperative phase of care. Within each phase, recommendations were synthesised inductively into themes. Quality of CPGs was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

RESULTS

From 4707 citations, 13 guidelines were included; 8/13 were focused on the perioperative care of older surgical patients in general. Among 110 recommendations extracted, 37 themes were generated, with the majority pertaining to preoperative care. Four themes were supported by strong evidence: performing preoperative frailty assessments, using multidimensional frailty instruments, reducing urinary catheter use, and following multidisciplinary care and communication throughout the perioperative period. Per AGREE II, most guidelines (8/13; 62%) were recommended for use with modifications.

CONCLUSIONS

Despite increasing numbers of patients living with frailty, few guidelines exist that address frailty-specific perioperative care. Given the lack of strong evidence-based recommendations, particularly outside the preoperative period, high-quality primary research is required to underpin future guidelines and better inform the care of older surgical patients with frailty.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022320149.

Epigenome-wide association studies of meat traits in Chinese Yorkshire pigs highlights several DNA methylation loci and genes

In this study, we aimed to identified CpG sites at which DNA methylation levels are associated with meat quality traits in 140 Yorkshire pigs, including pH at 45 min (pH_45min), pH at 24 h (pH_24h), drip loss (DL), meat redness value (a*), yellowness (b*) and lightness (L*). Genome-wide methylation levels were measured in muscular tissue using reduced representation bisulfite sequencing (RRBS). Associations between DNA methylation levels and meat quality traits were examined using linear mixed-effect models that were adjusted for gender, year, month and body weight. A Bonferroni-corrected p-value lower than 7.79 × 10 - 8 was considered statistically significant threshold. Eight CpG sites were associated with DL, including CpG sites annotated to RBM4 gene (cpg301054, cpg301055, cpg301058, cpg301059, cpg301066, cpg301072 and cpg301073) and NCAM1 gene (cpg1802985). Two CpG sites were associated with b*, including RNFT1 and MED13 (cpg2272837) and TRIM37 gene (cpg2270611). Five CpG sites were associated with L*, including GSDMA and LRRC3C gene (cpg2252750) and ENSSSCG00000043539 and IRX1 gene (cpg2820178, cpg2820179, cpg2820181 and cpg2820182). No significant associations were observed with pH_45min, pH_24h or a*. We reported associations of meat quality traits with DNA methylation and identified some candidate genes associated with these traits, such as NCAM1, MED13 and TRIM37 gene. These results provide new insight into the epigenetic molecular mechanisms of meat quality traits in pigs.

A Qualitative Method for Learning Medical Expert Reasoning

The aim of this paper is to propose a qualitative method for learning a model that represents the closest possible experts reasoning and strategies to provide recommendations of antibiotics. The learned model contains an integrity constraint and a preference formula. The former indicates the features that an antibiotic should have to be recommended. The later indicates the rank of recommendation of an antibiotic.

Distributed-force-feedback-based reflex with online learning for adaptive quadruped motor control

Biological motor control mechanisms (e.g., central pattern generators (CPGs), sensory feedback, reflexes, and motor learning) play a crucial role in the adaptive locomotion of animals. However, the interaction and integration of these mechanisms - necessary for generating the efficient, adaptive locomotion responses of legged robots to diverse terrains - have not yet been fully realized. One issue is that of achieving adaptive motor control for fast postural adaptation across various terrains. To address this issue, this study proposes a novel distributed-force-feedback-based reflex with online learning (DFRL). It integrates force-sensory feedback, reflexes, and learning to cooperate with CPGs in producing adaptive motor commands. The DFRL is based on a simple neural network that uses plastic synapses modulated online by a fast dual integral learner. Experimental results on different quadruped robots show that the DFRL can (1) automatically and rapidly adapt the CPG patterns (motor commands) of the robots, enabling them to realize appropriate body postures during locomotion and (2) enable the robots to effectively accommodate themselves to various slope terrains, including steep ones. Consequently, the DFRL-controlled robots can achieve efficient adaptive locomotion, to tackle complex terrains with diverse slopes.

Breast Cancer Predisposition Genes and Synthetic Lethality

BRCA1 and BRCA2 are tumor suppressor genes with pivotal roles in the development of breast and ovarian cancers. These genes are essential for DNA double-strand break repair via homologous recombination (HR), which is a virtually error-free DNA repair mechanism. Following BRCA1 or BRCA2 mutations, HR is compromised, forcing cells to adopt alternative error-prone repair pathways that often result in tumorigenesis. Synthetic lethality refers to cell death caused by simultaneous perturbations of two genes while change of any one of them alone is nonlethal. Therefore, synthetic lethality can be instrumental in identifying new therapeutic targets for BRCA1/2 mutations. PARP is an established synthetic lethal partner of the BRCA genes. Its role is imperative in the single-strand break DNA repair system. Recently, Olaparib (a PARP inhibitor) was approved for treatment of BRCA1/2 breast and ovarian cancer as the first successful synthetic lethality-based therapy, showing considerable success in the development of effective targeted cancer therapeutics. Nevertheless, the possibility of drug resistance to targeted cancer therapy based on synthetic lethality necessitates the development of additional therapeutic options. This literature review addresses cancer predisposition genes, including BRCA1, BRCA2, and PALB2, synthetic lethality in the context of DNA repair machinery, as well as available treatment options.

The execution of movement: a spinal affair

In this tribute to Reggie Edgerton, I briefly review the spinal mechanisms that coordinate locomotion and the interaction between the different sensory mechanisms that help coordinate the locomotor movements and the central locomotor network. The step cycle has four distinct parts, the support phase, the lift off, the flexion phase, and, the most complex, the touch down, when the limb makes a smooth contact with ground again. Each of these phases is affected by different sensory mechanisms, which interact with the central network [central pattern generator (CPG)] generating the basic movements with its four components. Conversely, the CPG also gates the sensory reflex pathways, so that they are active only in a given phase of the step cycle, or even produces opposite effects in different parts of the step cycle. These different examples from mammals are most likely important also to consider for human locomotion and, in particular, in patients with spinal cord injury, partial or complete.

General Principles of Neurorobotic Models Employing Entrainment and Chaos Control

Neurorobotic models are perfect candidates for proving the validity of embodied/dynamical approaches to cognition. In order to control bodies of arbitrary complexity in complex environments, it is necessary to coordinate vast numbers of sensory and motor components. In this review, we took at several studies of neurorobotics and generalize common principles of how they achieve this massive feat, relying on the key concepts of entrainment and chaos control. We discuss current limitations and ways that these techniques could be expanded to cover more wide ranges of behavior, for example by taking inspiration from ecological psychology.

A Descending Circuit Derived From the Superior Colliculus Modulates Vibrissal Movements

The superior colliculus (SC) is an essential structure for the control of eye movements. In rodents, the SC is also considered to play an important role in whisking behavior, in which animals actively move their vibrissae (mechanosensors) to gather tactile information about the space around them during exploration. We investigated how the SC contributes to vibrissal movement control. We found that when the SC was unilaterally lesioned, the resting position of the vibrissae shifted backward on the side contralateral to the lesion. The unilateral SC lesion also induced an increase in the whisking amplitude on the contralateral side. To explore the anatomical basis for SC involvement in vibrissal movement control, we then quantitatively evaluated axonal projections from the SC to the brainstem using neuronal labeling with a virus vector. Neurons of the SC mainly sent axons to the contralateral side in the lower brainstem. We found that the facial nucleus received input directly from the SC, and that the descending projections from the SC also reached the intermediate reticular formation and pre-Bötzinger complex, which are both considered to contain neural oscillators generating rhythmic movements of the vibrissae. Together, these results indicate the existence of a neural circuit in which the SC modulates vibrissal movements mainly on the contralateral side, via direct connections to motoneurons, and via indirect connections including the central pattern generators.

The subesophageal ganglion modulates locust inter-leg sensory-motor interactions via contralateral pathways

The neural control of insect locomotion is distributed among various body segments. Local pattern-generating circuits at the thoracic ganglia interact with incoming sensory signals and central descending commands from the head ganglia. The evidence from different insect preparations suggests that the subesophageal ganglion (SEG) may play an important role in locomotion-related tasks. In a previous study, we demonstrated that the locust SEG modulates the coupling pattern between segmental leg CPGs in the absence of sensory feedback. Here, we investigated its role in processing and transmitting sensory information to the leg motor centers and mapped the major related neural pathways. Specifically, the intra- and inter-segmental transfer of leg-feedback were studied by simultaneously monitoring motor responses and descending signals from the SEG. Our findings reveal a crucial role of the SEG in the transfer of intersegmental, but not intrasegmental, signals. Additional lesion experiments, in which the intersegmental connectives were cut at different locations, together with double nerve staining, indicated that sensory signals are mainly transferred to the SEG via the connective contralateral to the stimulated leg. We therefore suggest that, similar to data reported for vertebrates, insect leg sensory-motor loops comprise contralateral ascending pathways to the head and ipsilateral descending ones.

Descending propriospinal neurons mediate restoration of locomotor function following spinal cord injury

Following spinal cord injury (SCI) in the lamprey, there is virtually complete recovery of locomotion within a few weeks, but interestingly, axonal regeneration of reticulospinal (RS) neurons is mostly limited to short distances caudal to the injury site. To explain this situation, we hypothesize that descending propriospinal (PS) neurons relay descending drive from RS neurons to indirectly activate spinal central pattern generators (CPGs). In the present study, the contributions of PS neurons to locomotor recovery were tested in the lamprey following SCI. First, long RS neuron projections were interrupted by staggered spinal hemitransections on the right side at 10% body length (BL; normalized from the tip of the oral hood) and on the left side at 30% BL. For acute recovery conditions (≤1 wk) and before axonal regeneration, swimming muscle burst activity was relatively normal, but with some deficits in coordination. Second, lampreys received two spaced complete spinal transections, one at 10% BL and one at 30% BL, to interrupt long-axon RS neuron projections. At short recovery times (3-5 wk), RS and PS neurons will have regenerated their axons for short distances and potentially established a polysynaptic descending command pathway. At these short recovery times, swimming muscle burst activity had only minor coordination deficits. A computer model that incorporated either of the two spinal lesions could mimic many aspects of the experimental data. In conclusion, descending PS neurons are a viable mechanism for indirect activation of spinal locomotor CPGs, although there can be coordination deficits of locomotor activity.

NEW & NOTEWORTHY

In the lamprey following spinal lesion-mediated interruption of long axonal projections of reticulospinal (RS) neurons, sensory stimulation still elicited relatively normal locomotor muscle burst activity, but with some coordination deficits. Computer models incorporating the spinal lesions could mimic many aspects of the experimental results. Thus, after disruption of long-axon projections from RS neurons in the lamprey, descending propriospinal (PS) neurons appear to be a viable compensatory mechanism for indirect activation of spinal locomotor networks.