Body

For women with hormone receptor-positive breast cancer, long-term endocrine therapy can greatly reduce the risk of recurrence. Many women, especially those in underserved populations, do not continue treatment, however. A new Psycho-Oncology study uncovers some of the factors that may be involved.

In the study of 1,231 women who completed questionnaires, 59% reported at least one barrier to adhering to endocrine therapy. Three factors were identified as important: habit (challenges developing medication-taking behavior), tradeoffs (perceived side effects and medication safety concerns), and resource barriers (challenges related to cost or accessibility). Black race was associated with increased reporting of all three of these factors.

"Endocrine therapy can offer a big benefit for breast cancer survivors, but many of the strategies we use to help women who are struggling with medication adherence are only designed to address one barrier at a time," said lead author Jennifer Spencer, PhD, of the University of North Carolina at Chapel Hill. "Our study finds that there are at least three distinct kinds of barriers that women might experience when taking endocrine therapy--suggesting that intervention strategies that can help address multiple barriers at once might be more effective, especially for Black women."

A study of teenage girls' selfie-taking behaviors found that taking and sharing selfies on social media is not linked to poor body image or appearance concerns.

However, when adolescent girls spend too much time agonizing over which photo of themselves to post, or rely heavily on editing apps to alter their images, there may be cause for concern.

The study, by researchers at the University of Arizona, found that selfie editing and time invested in creating and selecting the perfect selfie were both related to self-objectification, which led to body shame, appearance anxiety and more negative appearance evaluations in teen girls.

"Self-objectification is the idea that you come to think of yourself as an external object to be viewed by other people," said senior study author Jennifer Stevens Aubrey, an associate professor of communication in the University of Arizona College of Social and Behavioral Sciences. "Your orientation to the world is not an internal one, where you're thinking about how you feel or what you know or what you can do, but rather what you look like to other people. The focus on taking the perfect selfie seems to be encouraging girls to learn to see themselves as external objects for people to look at and admire."

The researchers' findings, published in the Journal of Children and Media, were based on a study of 278 teenage girls, ages 14 to 17. The teens completed an online survey in which they answered questions about how often they share selfies on social media and how often they use specific photo editing techniques, such as reducing red eye or using an app to smooth their skin or make them appear thinner. They also responded to a series of statements designed to measure how much time and effort they spend selecting which selfies to share on social media - what researchers referred to in the paper as their level of "selfie investment."

In addition, the girls completed a series of questionnaires designed to measure their levels of self-objectification and appearance concerns.

"Our main finding was that we really shouldn't be too worried about kids who take selfies and share them; that's not where the negative effects come from. It's the investment and the editing that yielded negative effects," Aubrey said. "Selfie editing and selfie investment predicted self-objectification, and girls who self-objectify were more likely to feel shameful about their bodies or anxious about their appearance."

The researchers said they chose to focus on adolescent girls because they are especially vulnerable to self-objectification.

"Girls are socialized in a way that makes them self-objectify to a greater degree than boys would; that's a pretty consistent finding," said lead study author Larissa Teran, a doctoral candidate in the University of Arizona Department of Communication, who co-authored the study with Aubrey and doctoral student Kun Yan.

Girls also are more likely than boys to experience negative consequences, such as body image issues, as the result of self-objectification, which can in turn lead to problems like depression and eating disorders, the researchers said.

"Self-objectification is the pathway to so many things in adolescence that we want to prevent," Aubrey said. "So, interventions really should focus on how we can encourage girls to develop an awareness of themselves that's not solely hinged on what they look like to other people."

The researchers said parents and caregivers of adolescent girls should be aware of red flags on teens' phones, such as selfie editing apps or camera rolls teeming with selfies. If a teen seems to be selfie-obsessed, it might be time for a talk.

"Having those conversations at a very early age is one of the ways problems can be avoided in the future," Teran said.

The researchers also note that there can be different motivations for sharing selfies.

"Selfies are a part of the media landscape, but you should post them for reasons other than trying to get people to admire your appearance or your body," Aubrey said. For example, posting a selfie on vacation or with friends may be more about sharing an experience than focusing on appearance.

With an estimated 93 million selfies taken each day, they aren't going away anytime soon, nor should they, researchers said. Teran said the important thing to remember is: "Selfies aren't bad. Just don't obsess."

Maternal obesity may increase a child’s risk for attention-deficit hyperactivity disorder (ADHD), according to an analysis by researchers from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), part of the National Institutes of Health. The researchers found that mothers—but not fathers—who were overweight or obese before pregnancy were more likely to report that their children had been diagnosed with attention-deficit hyperactivity disorder (ADHD) or to have symptoms of hyperactivity, inattentiveness or impulsiveness at ages 7 to 8 years old. Their study appears in The Journal of Pediatrics.

The study team analyzed the NICHD Upstate KIDS Study, which recruited mothers of young infants and followed the children through age 8 years. In this analysis of nearly 2,000 children, the study team found that women who were obese before pregnancy were approximately twice as likely to report that their child had ADHD or symptoms of hyperactivity, inattention or impulsiveness, compared to children of women of normal weight before pregnancy.

The authors suggest that, if their findings are confirmed by additional studies, healthcare providers may want to screen children of obese mothers for ADHD so that they could be offered earlier interventions. The authors also note that healthcare providers could use evidence-based strategies to counsel women considering pregnancy on diet and lifestyle. Resources for plus-size pregnant women and their healthcare providers are available as part of NICHD’s Pregnancy for Every Body initiative.

The objective of this study was to compare the safety and antitumor activity of F14512 and etoposide phosphate in dogs with spontaneous non-Hodgkin lymphoma and to investigate the potential benefit of F14512 in P-glycoprotein overexpressing lymphomas.

Subgroup analysis of dogs with Pgp-overexpressing NHL showed a significant improvement in PFS in dogs treated with F14512 compared with etoposide phosphate.

F14512 showed strong therapeutic efficacy against spontaneous NHL and exhibited a clinical benefice in Pgp-overexpressing lymphoma superior to etoposide phosphate.

Dr. Pierre Boyé from OCR (Oncovet-Clinical-Research), in Loos France as well as Oncovet, in Villeneuve d'Ascq France and the Department of Small Animal Teaching Hospital at The Royal (Dick) School of Veterinary Studies and The Roslin Institute, University of Edinburgh, UK said in their Oncotarget article, "Comparative oncology has shown that naturally occurring canine cancers are of valuable and translatable interest for the understanding of human cancer biology and the characterization of new therapies."

Comparative oncology has shown that naturally occurring canine cancers are of valuable and translatable interest for the understanding of human cancer biology and the characterization of new therapies.

Dogs develop a broad spectrum of spontaneously occurring cancers that share strong similarities with human cancers, offering a singular opportunity to answer key questions and guiding the cancer drug development path in a manner not possible using more conventional models.

The antiproliferative activity of F14512 has been demonstrated to be superior to etoposide in numerous human cancer cell lines such as breast cancer, non-small cell lung cancer, leukemia, melanoma, ovarian cancer, and carcinomas.

In a vinorelbine-resistant P388 mouse leukemia cell line model overexpressing a high level of functional P-glycoproteins, F14512 displayed a strong antileukemic activity and the antitumor activity of F14512 was not impacted by the MDR status of cancer cells.

The Boyé Research Team concluded in their Oncotarget paper that the data reported here illustrate that spontaneous cancers in dogs offer a unique opportunity to integrate pet dog studies into the development paths of new cancer drugs.

With recent developments in prenatal screening, more parents are expected to receive a Down syndrome diagnosis before the birth of their child, which can involve complex decision-making for many. To understand what such a diagnosis means for parents who decide to continue their pregnancy and prepare for a child with Down syndrome (DS), the Dutch Down Syndrome Foundation surveyed 212 parents of children with DS born between 2010 and 2016.

The aim of this study was to describe their prenatal and postnatal experiences and better understand the way in which they had been informed about a possible and/or definitive diagnosis of DS in their child. During the study period, noninvasive prenatal screening (NIPS) was available as part of a nationwide program, offered as a secondary test after high-risk first-trimester combined testing (ftCT) result, from April 2014 onwards.

Results show that:

- The majority of the mothers in our study received the indication for/diagnosis of DS after their child was born, reflecting the relatively low uptake of prenatal screening for DS in the Netherlands during the study period (2010-2016). However, this finding also reflects the fact that the majority of cases where a prenatal diagnosis of DS was made was followed by an elective termination of pregnancy.

- 24% of mothers of a child with DS had had some testing (of which 9% had invasive testing and 13% a false negative ftCT result)

- 76% of women had chosen not to have prenatal testing, giving, on average, 3.8 reasons per mother for this decision: 81% gave at least one value-related reason such as "a child with DS is welcome in our family"; 34% gave at least one test-related reason such as "the fCT is not a good screening test"; 36% gave at least one information related reason such as "I assumed that in my case the chance for a child with Down syndrome was small."Only 1% mentioned cost as a reason.

- The mothers that were offered ftCT, 54% recalled that during the counseling of ftCT, no information regarding DS was provided. Only 17% of the women received information they considered sufficient both in terms of medical information and about living with a child with DS.

- 3-26% of women judged the information received at possible or final diagnosis as completely insufficient; more women considered information provided prenatally as insufficient as compared to postnatal received information.

The study shows that most of the mothers of a child with DS born in the Netherlands between 2010 and 2016 have consciously chosen not to have prenatal testing. This may be considered as an informed choice, as the majority of these mothers felt that a child with DS was welcome in their family. Some mothers decided not to have testing because of the poor quality of the available screening test or they did not consider themselves to be at risk, which might reflect a lack of information. More than half of the women did not recall having received information on DS at all prior to choosing whether or not to have ftCT, which might as well indicate that the information provided at that moment was incomplete.

When receiving the diagnosis, not only is the information important, but the perceived atmosphere is crucial on how the conversation will be judged. The atmosphere is determined by level of empathy. Terms as "respect, warmth, and support" were used for positive-rated conversations, while words as "hasty, negative, cool, and distant" were used for negative-rated conversations.

From the results of this study, satisfaction was highest among those mothers who had received a confirmed postnatal diagnosis and lowest among women receiving a prenatal screening result indicative for DS, potentially related to the available options and difficult choices being discussed. As presented in this study, parents continuing their pregnancy prefer to receive positive information on DS, focused on the future. Apparently, this is more likely to be discussed in postnatal situations.

Discussing prenatal options in a balanced way can be challenging, particularly when parents already have an unspoken preference toward one pregnancy option, as reflected in the results of this study. Careful exploration of preferences seems to be crucial, and adequate use and compliance to existing guidelines would be helpful.

Hepatocellular carcinoma, a very common liver cancer linked to the presence of fat in the liver, is one of the leading causes of cancer death worldwide. With the increase in our sedentary lifestyle and in the sugar and fat content of our diet, the number of individuals at risk is on the rise. Scientists at the University of Geneva (UNIGE) have discovered a protein involved in the progression of a "fatty liver" towards cancer. This protein, S100A11, could not only allow early detection of the risk of developing liver cancer, but also open the way to new targeted therapies. These results, published in the journal Gut, highlight the close links between our diet and cancer development.

Hepatocellular carcinoma is the most common liver cancer. It can occur in the context of a chronic liver inflammation caused by excessive fat accumulation. Obesity is therefore an important risk factor for the development of this cancer. The difficulty in detecting it and the lack of targeted treatment contribute to the severity of this disease, which causes the death of more than 700,000 people per year worldwide. Moreover, with almost 41% of the Swiss population being overweight or obese, the extent of this cancer is likely to alarmingly increase in the next decades.

When fat triggers liver sickness

Among the largest organs in our body, the liver performs essential functions and is involved in the storage of sugars and fats from food. If the diet is too caloric, liver cells accumulate the excess of energy under the form of fat, a pathological condition called fatty liver disease. Inflammation and build-up of fibrous tissue can then develop and even lead to cirrhosis or cancer. These dysfunctions, initially asymptomatic, often go unnoticed or are considered benign. "We already know that a fatty liver can become inflamed and progress into cancer, but very little is known about the molecular mechanisms responsible for these pathologies", explains Michelangelo Foti, Professor and Director of the Department of Cell Physiology and Metabolism at UNIGE Faculty of Medicine, who supervised this work. "Fatty liver disease already affects nearly 30% of the world's population and will very quickly become a major public health problem."

A protein network involved

The aim of UNIGE researchers was to detect changes in the expression of specific proteins that could promote cancer development. "To date, studies have focused mainly on genetic mutations associated with liver cancer, but this has not led to effective treatments", adds Michelangelo Foti. "That is why we have been looking for other alterations that could explain the progression of a fatty liver towards an inflammatory state and cancer."

It turns out that a whole network of proteins becomes deregulated, in the absence of any genetic alterations, thereby creating an amenable environment to the development of cancer. Among this network, the protein S100A11 particularly caught the attention of scientists. "We first discovered that S100A11 promotes inflammation and build-up of fibrous tissue in the liver", explains Cyril Sobolewski, researcher at the Department of Cell Physiology and Metabolism and first author of this work. "Additional tests showed that the more S100A11 was expressed, the greater the severity of the cancer."

A therapeutic target?

The discrete symptoms of liver inflammation and cancer play an important role in their dangerousness, but the presence of S100A11 in the blood raises the possibility of an early detection by simple blood sampling. "The earlier the patient is treated, the greater the chances of survival", highlights Michelangelo Foti. "In addition, S100A11 may be a promising therapeutic target, says Cyril Sobolewski. The next step would be to generate specific antibodies able to neutralize the protein and prevent its carcinogenic effect." This type of approach, called immunotherapy, has already shown promising results in the fight against several cancers.

Fertility doctors in France have announced the birth of the first baby to be born to a cancer patient from an immature egg that was matured in the laboratory, frozen, then thawed and fertilised five years later.

A letter in the leading cancer journal Annals of Oncology [1] today (Wednesday) describes how the baby boy was born to a 34-year-old French woman [2] who was infertile because she had been treated with chemotherapy for breast cancer five years earlier. Before she started her cancer treatment, doctors removed seven immature eggs from her ovaries and used a technique called in vitro maturation (IVM) to enable the eggs to develop further in the laboratory.

The mature eggs were then frozen by means of vitrification, which freezes the eggs very rapidly in liquid nitrogen to reduce the chances of ice crystals forming and damaging the cell.

Until now, there have been no successful pregnancies in cancer patients after eggs that have undergone IVM and vitrification, although some children have been born as a result of IVM followed by immediate fertilisation and transfer to the patient without freezing.

Professor Michaël Grynberg, head of the Department of Reproductive Medicine and Fertility Preservation at the Antoine Béclère University Hospital, near Paris, France, is the first author of the letter.

"I saw the 29-year-old patient following her diagnosis of cancer and provided fertility counselling. I offered her the option of egg freezing after IVM and also freezing ovarian tissue. She rejected the second option, which was considered too invasive a couple of days after cancer diagnosis."

Ultrasound revealed there were 17 small fluid-filled sacs containing immature eggs in her ovaries. However, using hormones to stimulate her ovaries to ripen the eggs would have taken too long and could have made her cancer worse. Therefore, an emergency procedure was scheduled six days later without ovarian stimulation, and Prof Grynberg retrieved seven immature eggs before her chemotherapy started.

After five years, the patient had recovered from breast cancer but found the chemotherapy had made her infertile as she had been unable to conceive within a year. Stimulating her ovaries to prompt them to produce more eggs ran the risk that the hormones used could cause the breast cancer to recur, so she and her doctors decided to use her frozen eggs. All six eggs survived the thawing process and they were fertilised using ICSI (intracytoplasmic sperm injection); five fertilised successfully and one embryo was transferred to the patient's womb. She became pregnant and nine months later she gave birth to a healthy baby boy called Jules on 6 July 2019.

Prof Grynberg said: "We were delighted that the patient became pregnant without any difficulty and successfully delivered a healthy baby at term. My team and I trusted that IVM could work when ovarian stimulation was not feasible. Therefore, we have accumulated lots of eggs that have been vitrified following IVM for cancer patients and we expected to be the first team to achieve a live birth this way. We continue offering IVM to our patients in combination with ovarian tissue cryopreservation when ovarian stimulation cannot be considered. This success represents a breakthrough in the field of fertility preservation."

He concluded: "Fertility preservation should always be considered as part of the treatment for young cancer patients. Egg or embryo vitrification after ovarian stimulation is still the most established and efficient option. However, for some patients, ovarian stimulation isn't feasible due to the need for urgent cancer treatment or some other contraindication. In these situations, freezing ovarian tissue is an option but requires a laparoscopic procedure and, in addition, in some diseases it runs the risk of re-introducing malignant cells when the tissue is transplanted back into the patient.

"IVM enables us to freeze eggs or embryos in urgent situations or when it would be hazardous for the patient to undergo ovarian stimulation. In addition, using them is not associated with a risk of cancer recurrence.

"We are aware that eggs matured in the lab are of lower quality when compared to those obtained after ovarian stimulation. However, our success with Jules shows that this technique should be considered a viable option for female fertility preservation, ideally combined with ovarian tissue cryopreservation as well."

Research Suggests No Difference in Morning Versus Evening Dosing for Warfarin

Patients taking warfarin to reduce the risk of stroke and pulmonary embolisms are often advised to take the medication in the evening. But does time of day really matter? A new study shows evidence that morning versus evening dosing has insignificant bearing on how long the drug provides the most benefit for preventing adverse health events. Two hundred and seventeen adults who regularly used warfarin in the evenings were randomized to the trial, with about half switching to morning medication use for seven months. Researchers measured the effectiveness of the drug by tracking the proportion of time that patients spent outside of the range for maximum effectiveness of the drug. Therapeutic changes did not significantly differ for patients who switched to morning administration. The clinical research team concluded that the time of day a patient takes the medicine has no effect on the stability of warfarin's anticoagulant effect. Patients should take warfarin whenever regular compliance would be easiest.

The Effect of Warfarin Administration Time on Anticoagulation Stability (INRange): A Pragmatic Randomized Controlled Trial
Scott R. Garrison MD, PhD, et al
University of Alberta, Department of Family Medicine, Edmonton, Alberta, Canada
http://www.annfammed.org/content/18/1/42

When the Best Treatment for Hypertension is to Wait: A Study of "Therapeutic Inertia" and Home Blood Pressure Follow-Up

A new study from the University of Missouri concluded that a physician's decision not to intensify hypertension treatment is often a contextually appropriate choice. In two-thirds of cases where physicians did not change treatment for patients with hypertension, patients' blood pressure returned to normal in follow-up readings taken at home. This pre- and post-study tracked 90 patients with hypertension to understand the role that follow-up home blood pressure measures could play in understanding cases of "therapeutic inertia." Sixty-six percent of patients who had a blood pressure reading of 140/90 or higher when they were in the clinic and whose doctors did not change their treatment, had average readings under 140/90 when patients took their blood pressure at home.

According to the authors, there are implications for health care quality metrics. Doctors' success rates in controlling hypertension are based solely on clinic blood pressure rates. The authors extrapolated the home blood pressure metrics to show that when home metrics replaced clinical ones, the department's hypertension control success rates rose from 58% to 86%. They conclude, "Most validated home blood pressure should be accepted and preferred for physician hypertension performance measures."

Additionally, when surveyed after the home blood pressure reading intervention, participants shared that home blood pressure monitoring enhanced their understanding of blood pressure control. Eighty-three percent of participants agreed that they would consider buying a home blood pressure monitor if it was covered by insurance.

Home Blood Pressure Monitoring in Cases of Clinical Uncertainty to Differentiate Appropriate Inaction From Therapeutic Inertia
Sonal J. Patil, MD, MSPH, et al
University of Missouri, Department of Family and Community Medicine, Columbia, Missouri
http://www.annfammed.org/content/18/1/50

A Blueprint for Building Transgender Health Programs in Primary Care

Leading educators and clinical experts on transgender health care from Harvard, Fenway Health, and The Fenway Institute address access issues for transgender patients seeking care by providing a plan to integrate gender-affirming hormone therapy, surgical referrals, or wrap-around services into primary care. Such programs provide a much-needed service for this underserved but increasingly visible population that experiences significant health inequities. Authors provide a concise and practical guide to developing transgender health programs within existing primary care practices. Programs may be as streamlined as having one or two clinicians who provide hormone therapy within a welcoming primary care practice. The guide provides tips on how to access low-cost clinical training and how to generate organizational buy-in for the development of new services. The plan can be adapted across primary care practices of varying sizes and resources. This is the first peer-reviewed publication that provides a guide to implementing a transgender health program in primary care settings.

A Blueprint for Planning and Implementing a Transgender Health Program
Alex S. Keuroghlian, MD, MPH, et al
The Fenway Institute, Harvard Medical School, and Massachusetts General Hospital, Department of Psychiatry, Boston, Massachusetts
http://www.annfammed.org/content/18/1/73

Cancer Screening Among Women Prescribed Opioids

U.S. women who take prescription opioids are no less likely to receive key cancer screenings when compared to women who are not prescribed opioids. Researchers at the University of California, Davis analyzed data from a nationally representative sample of 53,982 women in the United States. Findings revealed that women who are prescribed opioids were more likely to receive breast, cervical, and colorectal cancer screenings for the simple fact that they are frequent users of the health care system. They had a median number of doctor visits that was five times higher than their non-prescribed counterparts. When this factor was controlled for, analysis showed no association between prescription opioid use and cancer screening. This study is one of the first to examine access to key preventive health services for opioid versus non-opioid users. Authors suggest that "the key driver of whether women receive recommended cancer screening is simply how often they see the doctor."

Cancer Screening Among Women Prescribed Opioids: A National Study
Alicia Agnoli, MD, MPH, MHS, et al
University of California, Davis School of Medicine, Department of Family and Community Medicine, Sacramento, California
http://www.annfammed.org/content/18/1/59

Social Factors Play a Key Role in Missed Well-Child Care Visits

Despite the benefits of well-child care visits (WCV), up to half of WCVs are missed. A team of researchers and pediatricians at Virginia Commonwealth University, University of Washington, and the University of Vermont sought to understand the challenges that prevent families from attending their child's scheduled appointment. They interviewed caregivers of children who had missed WCVs as well as family and pediatric physicians from a large safety-net health system in Richmond, Virginia. Caregivers and physicians alike identified social factors as key barriers to attendance, including transportation, difficulty taking time off from work, childcare, and underlying financial stressors. The researchers conclude, "Our findings suggest there is a need to further explore the potential relationship between WCV attendance and social determinants of health."

Caregiver and Clinician Perspectives on Missed Well-Child Visits
Elizabeth R. Wolf, MD, MPH, et al
Virginia Commonwealth University, Department of Pediatrics, and the Children's Hospital of Richmond at VCU, Richmond, Virginia
http://www.annfammed.org/content/18/1/30

Certification as a Medical Home: Does It Make a Difference in Diabetes Care?

Researchers compared 258 certified medical home primary care practices in Minnesota to 136 non-certified practices, to see if certification had any bearing on performance measures related to the quality of diabetes care. Certified practices were found to have slightly more medical home practice systems than uncertified practices. Additionally, certified practices had somewhat better performance outcomes on quality measures related to diabetes care. Uncertified practices, comprising 39 percent of the surveyed practices, were noted to be more rural but had similar patient populations. Practices certified as medical homes have more systems and improved performance for diabetes care, but the differences are modest.

Differences in Diabetes Care With and Without Certification as a Medical Home
Leif I. Solberg, MD, et al
HealthPartners Institute, Minneapolis, Minnesota
http://www.annfammed.org/content/18/1/66

Primary Care Patients Assess eConsult Model for Provider-to-Specialist Consultations

A study across five academic medical centers examined the reaction of patients to the use of an electronic consultation (eConsult) service for primary care provider-to-specialist consultation. This focus group study of adult primary care patients was conducted to better understand patients' opinions, as most previous eConsult studies focused on clinical and financial impacts and clinician responsibility. Fifty-two participants across five focus groups were introduced to the eConsult model and were asked to discuss potential benefits and drawbacks, as well as acceptability of a hypothetical copay and preferences for involvement in future eConsult decision making and communication. Participants in all five focus groups reacted favorably to the eConsult concept; quicker access to specialty care and convenience were cited as key benefits, with approval rates particularly high among those having a trusted primary care provider. Some patients wanted to be involved in eConsult decision making and communication. They also expressed a decreased enthusiasm about eConsults if a copay were to be introduced. A small number of participants were also concerned about potential misuse of the system and about the exclusion of the patient's illness narrative in the eConsult exchange.

Patients Assess an eConsult Model's Acceptability at 5 US Academic Medical Centers
Sara L. Ackerman, PhD, MPH, et al
University of California, San Francisco, California
http://www.annfammed.org/content/18/1/35

Offering Cognitive Behavior Therapy Programs for Diabetes Self-Management Leads to Improved Physical Activity and Health Outcomes

A peer-delivered program for managing diabetes and chronic pain was shown to be beneficial for rural adults in communities that might otherwise lack access to physician-led services. Trained community members in rural Alabama delivered a diabetes self-management program that incorporated cognitive behavioral approaches to overcoming pain as a barrier to physical activity. Peer trainers were African American women who had personal experiences with diabetes and were lifelong community members. Similarly, participants were mostly low-income African American women recruited through community connections and assigned to the intervention by town block randomization. Adults who completed the 10-week program showed significant improvements in functional status, pain, and quality of life, when compared to a peer-led general health advice control group. At the end of the program, adults in the cognitive behavioral therapy-based program were more likely to report having no pain or finding alternative exercises when pain prevented them from walking. These results demonstrate that peers trained to deliver CBT-based interventions can improve health outcomes in areas where access is limited.

Peer-Delivered Cognitive Behavioral Training to Improve Functioning in Patients With Diabetes: A Cluster-Randomized Trial
Monika M. Safford, MD, et al
Weill Cornell Medicine, Department of Medicine, New York, New York
http://www.annfammed.org/content/18/1/15

Health Coaching Shown to Improve Inhaler Use Among Low-Income COPD Patients

Over 14 million U.S. adults have chronic obstructive pulmonary disease, and many face barriers to using inhaled medications regularly and effectively. Although inhaled medications can improve daily life and long-term outcomes, only 25 to 43% of people with COPD use them regularly. In addition, inhalers can be complex to use--requiring users to master a series of six to eight steps that differ across devices. Physicians and health teams have not yet found a solution to bring COPD medication adherence to the level of other chronic diseases.

In a multi-site randomized controlled trial from the University of California, San Francisco, non-licensed, trained health coaches offered COPD patients one-on-one support in person and by phone, with contact at least every three weeks for nine months. Participants were primarily low-income, African American and Latino men in an urban area. Those who received health coaching showed significant improvement in adherence to controller inhalers and improved inhaler technique, with 40% of health-coached patients versus 11% of a control group able to demonstrate effective use of their inhalers after the intervention. Researchers conclude that "improved inhaler technique and adherence are one of multiple factors contributing to long-term COPD outcomes, but their research has confirmed one technique--use of lay health coaches--that may help patients get optimal benefit from their COPD medications.

Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial
Rachel Willard-Grace, MPH, et al
University of California, San Francisco, Department of Family and Community Medicine, San Francisco, California
http://www.annfammed.org/content/18/1/5

Lay Health Coaches "Share-the-Care" to Reduce Health Disparities

In an accompanying editorial, Sonal J. Patil summarizes two recent studies on lay health coaching in chronic disease self-management for low-resource, predominantly African American communities. Self-management training and support programs exist to support patients with chronic diseases like diabetes and chronic obstructive pulmonary disease. However, these programs are not equally utilized. Inequities in education, geographic accessibility, and other social factors can make it even harder for certain populations to access the coaching. Patil stresses the ability of peer coaching to adapt one-size-fits-all disease management training, helping patients fit interventions to their personal preferences and social context. Despite their potential utility in addressing health disparities, Patil notes that funding for lay health coaches can be precarious. Payment is often challenged by the lack of widespread reimbursement from insurers. Patil concludes, "Lay health coaches can potentially 'share-the-care' in communities, by assisting with the 'work of being a patient' with chronic disease, to supplement primary-care visits in low-resource settings where 'no moment is wasted.'"

Task Sharing Chronic Disease Self-Management Training With Lay Health Coaches to Reduce Health Disparities
Sonal J. Patil, MD, MSPH
University of Missouri, Department of Family and Community Medicine, Columbia, Missouri
http://www.annfammed.org/content/18/1/2

Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in Japan

A comparison of the strengths and challenges of primary care between hospital-based practices and community-based office practices was observed in a cross-sectional study in Japan. Each type of practice had its strengths in terms of patient experiences and challenges. Patients at community-based office practices reported better patient experiences of community orientation than those in hospital-based practices. Hospital-based practices were associated with better patient experience of first contact, compared with office-based practices. Six small and medium-sized hospitals and 19 community-based office practices participated in the study of 1,725 patients. Patient experience was measured using a Japanese version of the Primary Care Assessment Tool, which was comprised of first contact, longitudinality, coordination, comprehensiveness (services provided), and community orientation. Understanding the strengths of each practice type with respect to patient experience may inform future efforts to improve the patient experience overall.

Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in Japan
Takuya Aoki, MD, PhD, MMA, et al
Kyoto University, Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto, Japan
http://www.annfammed.org/content/18/1/24

The Phoenix: A 20-Year Patient-Doctor Healing Journey

Building from a previous story ("On Blindness and Blind Spots") while seeking a greater understanding of the psychological causes behind a longtime patient's many symptoms, the author's discovery of more traumatic events provides a new perspective for understanding her patient. The patient-narrator shares short, poetic pieces which help explain her difficult childhood experiences and her efforts as a grown woman to heal emotionally. The author notes the value of belief in one's patient, in addition to the patience and trust which can be built over many years between patient and physician. "As an experienced physician, I thought perhaps time would eventually unravel the many layers beneath the surface of your story. I have learned over the years that one of the benefits of caring for patients for what is now over two decades, is that a more comprehensive understanding of a patient's symptoms emerges only after many years."

The Phoenix: A 20-Year Patient-Doctor Journey
Ruth Kannai, MD, et al
Ben-Gurion University of the Negev, Department of Family Medicine, Beersheba, Israel
http://www.annfammed.org/content/18/1/80

Innovations in Primary Care

Innovations in Primary Care are brief, one-page articles that describe novel innovations from health care's front lines. In this issue:

Interdisciplinary Group Visits for Patients With Complex Social Needs - A redesigned Federally Qualified Health Center provided fluid and interdisciplinary care from a team of community health workers, public health nurse, behavioral health providers, family physician, pharmacist, and psychiatrist, with a combination of support from team members in any given patient visit.
http://www.annfammed.org/content/18/1/83

A new study in JNCI: Journal of the National Cancer Institute, published by Oxford University Press, finds significant benefits to lengthening the amount of time between prostate cancer screenings for men.

Prostate cancer is one of the most common cancers in men, affecting one in seven men over the course of his lifetime. A blood test called a prostate specific antigen (PSA) test, which measures the levels of PSA in the blood, has been used to screen for prostate cancer for decades, because levels of PSA in the blood can be higher in men who have prostate cancer. But PSA levels are higher in other conditions that affect the prostate, such as certain medical procedures and medications, as well as an enlarged prostate or a prostate infection. Research regarding the effectiveness of such screenings in identifying and treating men with prostate cancer has so far been inconclusive.

Previous studies have shown that men with low PSA levels (JNCI: Journal of the National Cancer Institute by Heijnsdijk and colleagues investigated benefits and harms of screening strategies associated with lengthening the screening interval when PSA is below 1.0 ng/mL at ages 45 or 50 or discontinuing screening when PSA is below 1.0 ng/mL at age 60.

Using statistical modeling techniques, they predicted the harms (measured in tests and overdiagnoses) and benefits (measured in lives saved and life-years gained) of PSA-stratified screening strategies versus the traditionally recommended screening for men between 45 and 69 every other year.

The models projected that screening 10,000 men ages 45 to 69 every other year would require more than 110,000 screens and result in up to 348 overdiagnoses. They found that lengthening the screening interval from two to eight years would result in a decrease of overdiagnosis by 5- 24%, and only 3.1 to 3.8% fewer lives saved.

Additionally the models predicted that discontinuing screening at age 60 for everyone would greatly reduce overdiagnoses (by 79-82%) but would save substantially fewer lives compared to screening until age 69.

"This study shows the power of comparative modeling: by using two models with different underlying assumptions, we can identify uncertainty around the outcomes," said lead author Eveline Heijnsdijk, PhD.

Due to Zika virus, more than 1,600 babies were born in Brazil with microcephaly, or abnormally small heads, from September 2015 through April 2016. The epidemic took health professionals by surprise because the virus had been known since 1947 and was not linked to birth defects.

As scientists scrambled to figure out what was going on, one fact stood out: 83% of microcephaly cases came from northeastern Brazil, even though Zika infections were recorded nationwide.

Researchers from Washington University School of Medicine in St. Louis since have learned that the strain of virus circulating in the northeastern Brazilian state of Paraíba in 2015 was particularly damaging to the developing brain. Kevin Noguchi, PhD, an assistant professor of psychiatry and the study's senior author, spoke about the findings, which are available online in The Journal of Neuroscience.

How did you determine that the Paraíba strain was unusually harmful?

We studied two strains of Zika virus - one from an outbreak in French Polynesia in 2013 that was associated with a low risk of microcephaly, and another from Paraíba in 2015. We infected one group of newborn mouse pups with one strain and a second group with the other strain. The brains of newborn mice are at a similar stage of development to a second-trimester human fetus, when Zika virus causes considerable damage. Each strain led to about the same number of deaths, but the brain damage in the surviving mice was dramatically different. The mice infected with the French Polynesian strain seemed to successfully fight off the infection within about two weeks after infection, and we did not see any additional signs of damage after that. In contrast, we saw neurodegeneration in the mice infected with the Paraíba strain up to 30 days later, and they had smaller brains.

Is that why babies born in Paraíba were at high risk of microcephaly?

Maybe. It tells us that the strain from Paraíba was more capable of causing severe brain damage than the one from French Polynesia. It doesn't rule out other possibilities.

For instance, other environmental factors in Paraíba - such as dengue or other viruses that were circulating at the same time - could have affected Zika's ability to overwhelm the body's defenses and cause severe brain damage.

What is it about the Paraíba strain that made it so dangerous?

That's our next step. We have started a collaboration with Dr. Luis Martínez-Sobrido, PhD, and his colleagues at the University of Rochester. They found a mutation in the Paraíba strain that may affect its virulence, or ability to cause disease.

If the Paraíba strain is so harmful, why didn't it cause an epidemic of microcephaly the next year?

Everyone was bracing for another massive increase in microcephaly the next year, but it didn't happen. We also saw more limited increases of microcephaly in other parts of Latin America and the Caribbean, even as the virus spread into those areas. Nobody really knows why. It could be that pregnant women started wearing more insect repellant and putting screens on their windows. In Brazil, it could be that so many people got infected the first year that many pregnant women were immune the next year. It's also possible that the virus was just too virulent for its own good. If you kill your host, you also kill the opportunity to get passed on to the next person. So it could be that Zika reached peak virulence in 2015 and then evolved to be less virulent over time. That's another thing we'd like to find out.

Having more nurses trained outside of the United States working on a hospital unit does not hurt collaboration among healthcare professionals and may result in a more educated and stable nursing workforce, finds a new study by researchers at NYU Rory Meyers College of Nursing published in the journal Nursing Economic$.

"While there have been concerns that internationally educated nurses may not perform at the same level as U.S.-trained nurses, including collaborating with colleagues, our study suggests that such concerns may not be necessary," said Chenjuan Ma, PhD, an assistant professor at NYU Meyers and the study's lead author.

Internationally educated nurses--who receive their primary nursing education outside of the country where they currently work--have become an important part of the nursing workforce in many countries. In the U.S., recruiting internationally educated nurses has been used to address nursing shortages. While the true number of internationally educated nurses in the U.S. is difficult to capture, it is estimated that 5.6 to 16 percent--or 168,000 to 480,000--of the country's more than 3 million nurses were educated in another country.

Internationally educated nurses often face challenges when transitioning to practice in the U.S. because of cultural, language, and healthcare system differences. While internationally educated nurses can help mitigate nursing workforce shortages, there is little research on their impact on quality of care and patient outcomes, and the findings have been mixed.

In this study, the researchers looked at the proportion of internationally educated nurses on hospital units and evaluated whether this affects collaboration among health professionals and other factors of hospital units. They used 2013 survey data from the National Database of Nursing Quality Indicators, analyzing responses from 24,045 nurses (2,156 of whom were trained outside the U.S.) working on 958 units across 160 U.S. acute care hospitals. Collaboration on a unit was measured using a nurse-nurse interaction scale and a nurse-physician interaction scale.

The researchers found having more internationally educated nurses did not lead to decreased collaboration among nurses and between nurses and physicians. This is important because collaboration among healthcare professionals is a fundamental aspect of quality work environments and can result in positive patient outcomes and satisfaction.

Interestingly, units with higher proportions of internationally educated nurses had notable differences, including factors that could both help and hurt patient care. For example, units with more internationally trained nurses had nurses with higher levels of education, which may be because internationally educated nurses are more likely to have a baccalaureate degree in order to qualify for and pass the U.S. nursing licensure exam.

"Research shows that having more nurses with bachelor degrees improves patient safety, so it is possible that internationally educated nurses are contributing to improved health outcomes," said Ma.

Units with more internationally trained nurses also had less turnover, as these nurses are likely to stay in a job longer than their U.S.-educated peers.

"In other words, units with more internationally educated nurses have a more stable nursing workforce. Not only can lower turnover rates reduce recruiting and hiring expenses, but they are also linked to fostering collaborative environments among nurses," said Ma.

In contrast, units with more internationally trained nurses had worse nurse staffing levels or higher patient-to-nurse ratios, despite these nurses being recruited to address shortages. Worse staffing levels have been shown to hurt collaboration and could potentially worsen patient outcomes.

The researchers note that hospitals and nurse recruitment agencies can play important roles helping to integrate internationally educated nurses into the U.S. workforce--for instance, providing training on the basics of the U.S. healthcare system, creating peer mentoring programs, and running workshops on culture, communication, and teamwork.

"Given the ongoing nursing workforce shortage, especially in rural areas, nurse managers and hospital administrators should not be reluctant to hire qualified internationally educated nurses to fill vacancies," said Ma. "In addition, nurse managers and peer nurses should recognize the contributions of their internationally educated colleagues, who are part of more stable, educated nursing teams. Recognizing the value of individual nurses can lead to a healthy work environment and workforce, which contributes to high quality patient care and outcomes."

CHICAGO: Researchers have examined new geriatric-specific characteristics that appear to raise the risk of elderly surgical patients having an unplanned hospital readmission within a month of initially leaving the hospital. The new study is published online as an "article in press" on the Journal of the American College of Surgeons website in advance of print publication.

The four geriatric risk factors for readmission after general surgical procedures are cognitive impairment requiring another person to sign the patient's consent form for the operation (called "incompetent at admission"), use of a mobility aid, risk of falling at discharge from the hospital, and need for skilled home health care after going home.

"Our findings could impact clinical practice," said Florence E. Turrentine, PhD, RN, lead study author and associate professor in the department of surgery at the University of Virginia, Charlottesville. "It is not clear that hospitals are using geriatric variables in evaluating patients. Our results support screening for use of a mobility aid or having a surrogate sign consent when hospitals admit geriatric patients for surgical care."

Elderly individuals--those age 65 years or older--make up 43 percent of Americans undergoing an inpatient operation* and are more likely than younger patients to have postoperative complications, results of multiple studies show. More than one in 10 of the elderly patients in the new study had an unexpected readmission, according to study authors.

"Readmissions are stressful and expensive and Medicare reduces payments to hospitals with excess readmissions," said R. Scott Jones, MD, MS, FACS, a study coauthor and emeritus professor and chair of the University of Virginia's surgery department. "We want to anticipate and hopefully prevent the reasons that contribute to unplanned readmission after an operation."

The University of Virginia was among 25 participating centers in the Geriatric Surgery Pilot study, which the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) created in 2014 to collect risk factors and outcomes in surgical patients 65 and older. The NSQIP database is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care in hospitals.

Using the first three years of data from that pilot study, Dr. Turrentine's research team tested 13 geriatric characteristics and 26 NSQIP risk factors for complications in 6,039 elderly general surgery patients from the NSQIP database.

The investigators evaluated statistically significant predictors of readmission within 30 days following the operation, both overall and for each of five surgical procedure groups. The groups were surgical removal of part or all of the (1) pancreas or liver, (2) colon and/or rectum (comprising 58 percent of the patients), (3) hernia, (4) thyroid or esophagus, and (5) appendix.

Readmission risk factors

Overall, the greatest odds of readmission were with the occurrence of any 30-day postoperative complication (odds ratio 5.1) and the need for a reoperation (odds ratio 2.8)--both NSQIP risk factors. However, the researchers noted their ability to predict readmission risk improved with the added geriatric-specific risk factors. Compared with patients who lacked the risk factor being measured, patients with the following geriatric characteristics had higher readmission odds ratios:

Incompetent at admission: 1.6
Fall risk at discharge: 1.4
Use of a mobility aid: nearly 1.3
Discharged from the hospital needing skilled care: 1.2

When the researchers looked at geriatric risk factors by procedure type, they discovered that use of a mobility aid had the highest readmission odds for the thyroid/esophagus group (odds ratio 11). The greatest geriatric risk factor they reported for the pancreas/liver group was admission from a place other than home, with a 24.4 odds ratio. In the hernia group, the odds ratio for readmission was 2.2 if they needed a new mobility aid at discharge.

Preventing readmissions

"These study findings give surgeons more information to help elderly patients prepare better for an operation and to find specific ways to prevent unplanned readmissions," Dr. Turrentine said.

Preparation could include the ACS Strong for Surgery recommendations to improve fitness for an operation, including preoperative rehabilitation, she suggested. For example, she said physical therapy may lessen the chance of needing a mobility aid.

Additionally, some of the identified geriatric risk factors are now part of the NSQIP Surgical Risk Calculator, an online tool providing customized risk estimates for patients planning to have an operation.

Another strategy the researchers proposed to help reduce readmission rates is for the surgeon's office to check on elderly at-risk patients--especially those who needed a reoperation--by calling them at home after their discharge.

"Our results confirm the need for surgeons to use the geriatric-specific variables to assess the risk for elderly patients undergoing surgical care," Dr. Jones said. "The ACS is on the right track with its Geriatric Surgery Verification Program."

That program is implementing surgical standards designed for hospitals to improve the aging population's surgical care.

James "Mac" Hyman, the Evelyn and John G. Phillips Distinguished Professor in Mathematics at Tulane University, is using mathematical models to better understand and predict the spread of COVID-19 and to quantify the effectiveness of various efforts to stop it.

The goal of Hyman's work in "mathematical epidemiology" at the Tulane School of Science and Engineering, is to help the public health community understand and anticipate the spread of the infection and evaluate the potential effectiveness of different approaches for bringing it under control.

Hyman and colleagues at Georgia State University and the Public Health Agency of Canada recently had a paper on COVID-19 accepted by the journal Infectious Disease Modeling and the Journal of Clinical Medicine.

The paper is based on daily reported cases of the virus for each Chinese province from the National Health Commission of China. The paper provides a methodology to predict the number of new infections five, 10, and 15 days in the future for the current epidemic in China.

In the paper, the authors say the predictions can help public health officials prepare the medical care and allocate resources needed to confront the epidemic, as well as to predict the intensity and type of interventions needed to mitigate an epidemic. In the absence of vaccines or antiviral drugs for the virus, the effective implementation of non-drug interventions, such as personal protection and social distancing, will be critical to bringing the epidemic under control.

COVID-19 is a disease caused by a virus named SARS-CoV-2. It is a member of the coronavirus family that's a close cousin to the SARS and MERS viruses that have caused outbreaks in the past.

Last week, Hyman led a workshop titled "Modeling Emerging Infection Diseases," and the coronavirus was a major topic of discussion along with Chagas disease, Dengue fever, and Zika. Among those in attendance were researchers from Tulane, the University of Michigan, the California Academy of Sciences, and the University of Louisiana at Lafayette.

The workshop focused on improving the quality of mathematical models to help guide public health workers to mitigate emerging infections. The goals include identifying the essential problems where modeling can be useful and forming collaborations to address these problems.

"We're trying to create models that can be more effective in guiding public health efforts to mitigate an epidemic," Hyman said. "It's about figuring out what needs to be in a model to estimate the risk of someone being infected and predict the risk that an infected person will be to someone else.

"In the coronavirus, we must account for the way that an infected person can infect the environment, such as a table or door handle, and others can be infected, even if they don't have direct contact with an infected person."

In a note submitted to Science Translational Medicine, Hyman and colleagues said several groups are working independently to predict the spread of COVID-19 and that coordination among the groups is essential and should be supported by government agencies.

He thinks the World Health Organization needs to take the lead by organizing an international effort that focuses on three specific aims - predicting further spread of the virus in China, predicting its potential to spread elsewhere or under various conditions, and predicting the effectiveness of mitigation strategies, such as quarantine, contact reduction, hand hygiene and face masks.

"In the complex 'fog of an outbreak,' the world needs actions guided by expert consensus and, as emphasized in this editorial, further guided by data-driven models that explore response scenarios," he wrote.

WASHINGTON--The Endocrine Society today announced an update to its osteoporosis Clinical Practice Guideline to include recommendations for romosozumab, a new medication that was approved last year to treat postmenopausal women at high risk of fracture.

The U.S. Food and Drug Administration approved romosozumab in April 2019, a month after the guideline was published.

"We felt it was important to update our guideline to reflect the newest, most effective medication options available for patients with osteoporosis," said Clifford J. Rosen, M.D., director, Center for Clinical and Translational Research at the Maine Medical Center Research Institute in Scarborough. Rosen chaired the writing committee that developed the guideline.

"Romosozumab offers promising results for postmenopausal women with severe osteoporosis or who have a history of fractures," Rosen said. "It does, however, come with a risk of heart disease, so clinicians need to be careful when selecting patients for this therapy."

New recommendations from the guideline include:

Postmenopausal women who have a very high risk of fracture can be treated with romosozumab for up to one year, but women with a high risk of heart disease and stroke should not be considered for treatment with romosozumab, pending further studies.

Women who have been on romosozumab for a year should be treated with antiresorptive osteoporosis therapies to protect their bone health.

"Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update," was published in the Society's Journal of Clinical Endocrinology & Metabolism, online ahead of print.

Tailoring care for older patients who have had emergency surgery can reduce complications and deaths, decrease the length of hospital stays and cut down on the need for alternate care at discharge, according to a new study led a University of Alberta researcher.

Rachel Khadaroo said the connection between age-related frailty and an increased vulnerability to post-surgical complications and death has been increasingly well understood over the past 20 years.

"Older patients who come in for emergency surgery are extremely vulnerable because they don't have the preparation time that they get with elective surgery," said Khadaroo, an associate professor at the U of A and surgeon and critical care specialist at the University of Alberta Hospital. "I can't suggest that we delay your emergency surgery so that you can quit smoking and optimize your heart."

Khadaroo said the goal of the study was to find out whether redesigning the hospital care patients receive after emergency surgery could improve outcomes.

"I want patients to have a successful operation, be able to go home and have a great quality of life afterwards," she said.

The results showed that for patients who received the optimized care, major complications and deaths were reduced by 19 per cent, the average length of stay in hospital was three days shorter, and more patients returned home rather than needing continuing care.

"We've actually been able to make a difference with elder-friendly surgical care," said Khadaroo.

The study followed 684 patients at the University of Alberta and Calgary Foothills hospitals from 2014 to 2017. All were 65 years or older and living independently when they were admitted for emergency surgeries, ranging from appendicitis and gallstones to hernias and obstructed or perforated intestinal organs. One hundred fifty were classified as well, 395 as vulnerable or pre-frail and 139 as frail.

One hundred forty of the patients received the "Elder-Friendly Approaches to the Surgical Environment" (EASE) treatment program designed by Khadaroo's team, while the rest received standard care.

The EASE program included an assessment by a geriatrician within 48 hours of admission, being assigned to a special ward with other post-surgical seniors, modifications or removal of commonly prescribed medications, and early consultation on what kind of care would be required after discharge.

Khadaroo wrote a special set of doctor's orders for the intervention patients, which included delirium screening, early withdrawal of tubes and drains, early mobilization to get patients out of bed and walking around, and a medication review.

"My order set was unique because it tried to pre-empt problems," said Khadaroo. "For example, I ordered the removal of the urinary bladder tube as quickly as possible because the tube can increase the chance of infection. Any type of bag or line that you have also increases the chance that you're not going to walk very well."

"I also changed the dose of some of our pain drugs to be more elder-friendly--smaller doses more frequently--to reduce the chance of delirium, which is associated with an increased risk of death and worse chance of going home."

The intervention group of patients also participated in a bedside reconditioning program (BE FIT) that had them doing seated hip marches, wall-assisted calf raises and standing up from a chair.

"It is something that patients can do to help keep strong when they're in hospital," said Khadaroo. "There's not much to do around here, so why not keep your muscles as strong as possible?"

Khadaroo based her interventions on elder-friendly care models developed for acute care and orthopedic care. She said it is hard to tease out which intervention made the most difference because they were bundled, although she plans further study on getting patients out of bed early with her bedside reconditioning program.

She said the aging population and extended lifespans mean a growing number of emergency surgeries are being performed on older and frailer patients. Some suggest such patients should not be eligible for emergency surgery because of the increased risks, but Khadaroo said she would like to see standardized screening for frailty and improved post-surgical care for vulnerable patients.

She added that the EASE interventions have a relatively low cost because of savings related to fewer complications and readmissions, and shorter hospital stays.

"Our point is that elder-friendly care following an operation improves chances of better outcomes," she said. "We can get you better with fewer complications and a shorter hospital stay, if we have a co-ordinated, elder-friendly team approach."