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Purpose: We aimed to analyse the characteristics of geriatric courses offered to undergraduate medical students in higher educational institutions (HEIs) in Poland., Methods: We searched the official websites of the HEIs offering the medical degree programmes and directly contacted the dean's offices and HEIs representatives to retrieve the relevant information. The documents were analysed for course content, teaching methods, duration, and recommended texts. We also checked the obtained curricula for the reference to of the learning objectives related to geriatric medicine, selected from the currently endorsed Polish educational standards (ES) provided by the Ministry of Science and Higher Education., Results: Geriatric medicine courses were obligatory at all included HEIs (n = 19), but the courses differed in structure and content. The courses varied in duration from 11 to 60 h and were primarily lecture based. Simulation was utilized at only one HEI and e-learning at two institutions. Out of 315 learning objectives, we acknowledged only 9 as geriatric. They were not always found in all curricula. Two HEIs included self-described learning objectives in their curricula. Across all HEIs, a total of 29 recommended texts (published between 1995 and 2021) were identified, including 2 English-language texts., Conclusion: Geriatric medicine was a mandatory subject for medical students of the included HEIs. However, there was a lack of uniformity in the offered courses. This leaves room for the development of a unified undergraduate geriatrics curriculum to effectively address diverse geriatric issues across Europe. The importance of this matter is highlighted by demographic trends and workforce challenges., (© 2024. The Author(s).)

Purpose: Reduced appetite is a common issue among older adults. However, its formal assessment is rarely undertaken in clinical practice. The aim of the study was to check the frequency of reporting of appetite status in hospitalized older adults and to analyze the terms documented by physicians when reporting reduced appetite., Methods: A retrospective analysis of electronic medical records of hospitalized patients aged 65 and older was conducted. To determine patients' appetite status structured appetite assessment or any references related to appetite were considered., Results: We included 1291 individual patients' medical records, of which 13.3% contained any reference to appetite. We showed that in our setting, appetite was not assessed according to standardized questionnaires. In addition, appetite status was documented with inconsistent terminology., Conclusions: Appetite status was rarely noted in electronic medical records. The lack of a structured assessment of reduced appetite in older patients was found., (© 2024. The Author(s).)

Introduction: Interprofessional education (IPE) is an integrative approach that enables collaboration of students of two or more different health professions in aim to acquire skills and competencies related not only to their field of study but also to ensure the standard of care based on collaborative practice. IPE has not yet been explored in relation to collaboration between dietetics-nutrition and pharmacy students, while there is evidence that in many cases nutrition is complementary to pharmacotherapy in the treatment process., Aim: The aim of this scoping review was to gather, describe and discuss all relevant literature regarding joint interprofessional training of pharmacy and dietetics-nutrition undergraduates., Methods: We performed a literature search for studies where IPE between dietetics-nutrition and pharmacy students was described. 2204 articles on this topic were identified. After eligibility assessment, 8 articles were included in the review., Results: Eight studies were included in the review. Two of these described IPE activities between dietetics and pharmacy students only. The included studies varied in setting, methodology and outcome measures and covered a wide range of topics relevant to clinical practice, such as management of inflammatory bowel diseases, care of the older adults or counselling skills. The most common teaching method was the use of case studies. Some of the included studies did not identify specific learning objectives. The most common way of gathering feedback from participants was through questionnaires and interviews., Conclusions: IPE of pharmacy and dietetics-nutrition students is feasible and may be beneficial in many aspects related to learning. However, there is no well-established model or standard that would facilitate the implementation of such activities in individual educational institutions., (© 2024. The Author(s).)

Purpose: To present the two-day Delirium Awareness Day-related event held at the University Hospital, Kraków, Poland., Methods: Activities included a lecture, a multimedia presentation, meetings with healthcare workers at their respective wards, and distribution of information posters about delirium. Local news outlets were also engaged., Results: We reached out to approximately 300 persons in the hospital itself and several thousand via TV and radio broadcasts. We prompted interdisciplinary discussions about delirium, especially concerning preventive measures. The most common questions were how to alleviate symptoms as soon as possible, with the expectation of straightforward solutions for the non-geriatrician staff. Patient distress and burden on caregivers were important topics brought-up in the discussions., Conclusion: We demonstrated that our educational initiative was feasible and well-accepted among medical staff. Local media helped in building public understanding of delirium. Education about the syndrome should be one of the key societal tasks of geriatricians., (© 2024. The Author(s), under exclusive licence to European Geriatric Medicine Society.)

Introduction: Aneurysmal subarachnoid hemorrhage is a devastating type of stroke, associated with high mortality and morbidity. One of modifiable risk factors of aneurysm rupture is hypertension, however, it is still not clear whether any particular antihypertensive drugs play a significant role in the prevention of aneurysm rupture., Objectives: We decided to investigate whether there is any association between acetylsalicylic acid, α-blockers, β‑blockers, angiotensin‑converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, diuretics, statins, and anticoagulants and a risk of intracranial aneurysm rupture., Patients and Methods: We retrospectively analyzed 334 patients with ruptured and unruptured intracranial aneurysm. Based on logistic regression models, we obtained unadjusted and adjusted odds ratios (ORs) of subarachnoid hemorrhage associated with the use of vasoactive medications and with indices of tortuosity., Results: We found that β‑blocker intake was significantly related to higher tortuosity of the cerebral arteries. Also, the intake of β‑blockers (OR, 0.41; 95% CI, 0.21-0.77; P = 0.01) and statins (OR, 0.23; 95% CI, 0.05-0.68; P = 0.01) significantly decreased the risk of aneurysm rupture, a result driven by a decreased rupture risk of anterior circulation aneurysms. No such association was found for the posterior part of the cerebral circulation., Conclusions: Aneurysm located in the anterior cerebral circulation might be less likely to rupture if patients receive β‑blockers or statins.

Poland has a unique history of traditional Chinese medicine (TCM) dating back to the 17th century when Polish missionary Michael (Michał) Boym was a pioneer in the field. In the 20th century, his successor, Professor Zbigniew Garnuszewski, reintroduced acupuncture to medical practice in Poland. However, other methods of TCM and its holistic approach to patient care have not found their place in modern medicine in Poland. At present, the legal status of TCM in Poland remains unregulated, with TCM included in the broad spectrum of complementary and alternative medicine (CAM) practices. Few reports are available on the use of TCM methods among the Polish population. Integrative medicine combines conventional medicine with evidence-based CAM interventions and considers all aspects of a patient's health, including physical, emotional, mental, social, and environmental factors. An integrative healthcare model that incorporates TCM modalities and lifestyle recommendations as well as a whole person approach may provide a more sustainable solution for the constantly underfinanced Polish healthcare system, which faces challenges of multimorbidity in an aging society and limited access to care. The coronavirus disease 2019 pandemic, war in Ukraine, and ongoing climate crisis have underscored the need to strengthen the resilience of the Polish healthcare system and search for new solutions. A model of care that blends the best of biomedicine and TCM healing approaches may be a better option for both patients and the healthcare system in Poland. Please cite this article as: Rybicka M, Zhao J, Piotrowicz K, Ptasnik S, Mitka K, Kocot-Kępska M, Hui KK. Promoting whole person health: Exploring the role of traditional Chinese medicine in Polish healthcare. J Integr Med. 2023; 21(6): 509-517., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Shanghai Changhai Hospital. Published by Elsevier B.V. All rights reserved.)

Our study aimed to verify the hypothesis concerning low-frequency magnetic fields (LF-MFs)-related changes in cell viability through the biomechanism(s) based on calcineurin (CaN)-mediated signaling pathways triggered via ROS-like molecules. For experiments, Mono Mac 6 and U937 leukocytic cell lines were chosen and exposed to various LF-MFs and/or puromycin (PMC). The protein expression level of key regulatory proteins of calcium metabolism was examined by Western Blot analysis. In turn, the reactive oxygen species (ROS) and cell viability parameters were evaluated by cytochrome C reduction assay and flow cytometry, respectively. The simultaneous action of applied MF and PMC influenced cell viability in a MF-dependent manner. The changes in cell viability were correlated with protein expression and ROS levels. It was verified experimentally that applied stress stimuli influence cell susceptibility to undergo cell death. Moreover, the evoked bioeffects might be recognized as specific to both types of leukocyte populations., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Acute viral respiratory infections have proven to be a major health threat, even after the Corona Virus Disease 2019 (COVID-19) pandemic. We aimed to check whether the presence or absence of an acute respiratory infection such as COVID-19 can influence the physical activity of older hospitalised patients. We cross-sectionally studied patients aged ≥60 years, hospitalized during the pandemic in the non-COVID-19 and COVID-19 ward at the University Hospital, Kraków, Poland. Using activPAL3 ® technology, we assessed physical activity for 24 h upon admission and discharge. In addition, we applied the sarcopenia screening tool (SARC-F); measured the hand grip strength and calf circumference; and assessed the Modified Early Warning Score (MEWS), age-adjusted Charlson Index, SpO2%, and length of stay (LoS). Data were analysed using SAS 9.4. The mean (min, max) age of the 31 (58% women, eight with COVID-19) consecutive patients was 79.0 (62, 101, respectively) years. The daily time (activPAL3 ® , median [p5, p95], in hours) spent sitting or reclining was 23.7 [17.2, 24] upon admission and 23.5 [17.8, 24] at discharge. The time spent standing was 0.23 [0.0, 5.0] upon admission and 0.4 [0.0, 4.6] at discharge. The corresponding values for walking were 0.0 [0.0, 0.4] and 0.1 [0.0, 0.5]. SARC-F, admission hand grip strength, calf circumference, and LoS were correlated with physical activity upon admission and discharge (all p < 0.04). For every unit increase in SARC-F, there was a 0.07 h shorter walking time upon discharge. None of the above results differed between patients with and without COVID-19. The level of physical activity in older patients hospitalised during the pandemic was low, and was dependent on muscular function upon admission but not on COVID-19 status. This has ramifications for scenarios other than pandemic clinical scenarios.

Anorexia of aging is a common problem in older adults. Depending on the setting, its prevalence varies from about 10% (among community-dwelling older adults) to over 30% in acute wards and nursing homes. The objective of this systematic review was to establish the prevalence of poor appetite in frail persons ≥60 years of age. We performed a literature search for studies where the prevalence of anorexia of aging among frail and pre-frail old adults was reported. 957 articles on this topic were identified. After eligibility assessment, three articles were included in the review. The studies included 4657 community-dwelling older adults. The weighted total prevalence of anorexia of aging in all the included studies was 11.3%. Among frail and pre-frail participants, loss of appetite was reported in 20.5% (weighted estimate). Overall, robust status was associated with a 63% lower probability of concomitant anorexia of ageing (OR 0.37, 95%CI 0.21-0.65, p = 0.0005). Frailty or risk of frailty are associated with more prevalent anorexia of ageing. This has potential practical implications; however, more research, especially to elucidate the direction of the relation, is needed.

A significant proportion of the population aged 75 and over experiences an episode of major depression. Symptoms of depression manifested by elderly patients are sometimes treated as a natural element of the aging process, leaving elderly patients undiagnosed or misdiagnosed. It is postulated that the use of the Mediterranean diet may counteract the development of depression and alleviate depressive symptoms due to the anti-inflammatory properties of this diet. The aim of the systematic review was to assess whether the degree of adherence to the Mediterranean diet is related to the occurrence and severity of depressive symptoms in people over 65 years of age. We included 9 studies out of 317 identified manuscripts. The results of the studies included in the review indicate that adherence to the principles of the Mediterranean diet by elderly people may bring beneficial results in the prevention of depressive symptoms and justify further search for the relationship between this diet and its individual components with the mental well-being of old patients.

B a c k g r o u n d: Due to current increased life expectancy, the quality of life (QoL) of senior patients is gaining in importance. The aims of this study were: to estimate QoL in a group of patients, aged above 64 years, that is cared for by general practitioners (GPs) in Krakow, Poland, and to find relation- ships between elements of QoL and the results of comprehensive geriatric assessment (CGA) and other important medical and social factors. M e t h o d s: We designed a cross-sectional, questionnaire study among patients who attended GPs' surgeries from April 2018 to April 2019. To examine the patients, we used the Euro-Quality of Life Questionnaire (EQ-5D-5L) and eight scales forming CGA: the Activities of Daily Living, the Instrumental Activities of Daily Living, Mini-Mental State Examination, Geriatric Depression Scale, Timed Up and Go Test, Mini Nutritional Assessment, Clinical Frailty Scale and Athens Insomnia Scale. R e s u l t s: The lowest QoL was observed in dimensions of pain/discomfort and mobility, where 70% and 52% of patients, respectively, reported problems in these areas. Only 91 (21%) respondents had highest results in all five dimensions of QoL. The average score in the Visual Analogue Scale (VAS) of the EQ-5D-5L (representing self-rated health on a given day) was 62.36 ± 18.98 points. Statistically significant relationships were observed between QoL and age, physical activity and multimorbidity (in all cases p <0.001). The results of QoL were correlated with every aspect of CGA, while the strongest relationship was noticed between scores in the EQ-5D-5L VAS scale and scales assessing depression and frailty (p <0.001; r = -0.57 both).

Background: The prevalence of frailty and its components may be affected by age, diseases and geriatric deficits. However, the current operational definition of frailty assigns equal weight to the five components of frailty., Aims: To perform a population-based assessment of physical frailty, its prevalence, and distribution of its components across different age, disease and deficit spectrum., Methods: From 2018 to 2019, we conducted a face-to-face cross-sectional assessment of a representative sample of older Poles. We obtained data on frailty components, chronic disease burden, and prevalence of particular diseases and geriatric deficits. We calculated weighted population estimates, representative of 8.5 million older Poles, of prevalence of frailty and its components across the disease burden, associated with the particular diseases and the geriatric deficits present., Results: Of 10,635 screened persons ≥ 60 years, 5987 entered the face-to-face assessment. Data of 5410 have been used for the present analysis. Seventy-two percent of the population are burdened with at least one frailty component. The estimated weighted population prevalence (95% CI) of frailty was 15.9% (14.6-17.1%), and of pre-frailty 55.8% (53.3-58.2%). Slow gait speed predominated across disease burden, specific diseases, geriatric deficits and the age spectrum. Overall, the prevalence of slow gait speed was 56.3% (52.7-60.0%), followed by weakness 26.9% (25.4-28.4%), exhaustion 19.2% (17.6-20.8%), low physical activity 16.5% (14.8-18.3%), and weight loss 9.4% (8.4-10.3%)., Conclusions: Slow gait speed predominates among the components of frailty in older Poles. This may affect the component-tailored preventive and therapeutic actions to tackle frailty., (© 2023. The Author(s).)

Background: COVID-19 has affected older persons the most. The propensity to have severe COVID-19 or die of the infection was especially prevalent among older subjects with multimorbidity, frailty and sarcopenia. The aim of our study was to check which of the simple clinical biomarkers, including the assessment of muscle and frailty, would associate with the survival and the length of hospital stay in older patients with COVID-19. An additional aim was to report the influence of chronic diseases, chronic medication use, and COVID-19 signs and symptoms on the aforementioned outcome measures., Methods: The CRACoV study was a prospective single-center (University Hospital in Krakow, Krakow, Poland) observational study of clinical outcomes in symptomatic COVID-19 patients that required hospital treatment. We analysed data of persons aged ≥ 65 years. We assessed muscular parameters in accordance with EWGSOP2, frailty with the Rockwood Clinical Frailty Scale. We used the data of the initial and 3-month assessment. Demographic characteristics, past medical history, and baseline laboratory values were gathered as a part of routine care. We calculated sex and age, and additionally number-of-diseases adjusted odds ratios of mortality associated with studied factors and betas of the relation with these factors and the length of hospital stay., Results: The mean (standard deviation, SD) age of 163 participants (44.8% women, 14.8% died) was 71.8 (5.6) years, age range 65-89 years. One score greater SARC-F was associated with 34% (p = 0.003) greater risk of death, and 16.8 h longer hospital stay (p = 0.01). One score greater Rockwood was associated with 86% (p = 0.002) greater risk of death, but was unrelated to the length of hospital stay. Hand grip strength and dynapenia were unrelated to mortality, but dynapenia was related to longer hospital stay. Probable sarcopenia was associated with 441% (p = 0.01) greater risk of death., Conclusions: In conclusion, the patient assessment with SARC-F and the Rockwood Clinical Frailty Scale may significantly improve the prediction of outcomes in older patients with COVID-19 and by extension might be of use in other acute severe infections. This, however, requires further research to confirm., (© 2022. The Author(s).)

Background: Ankle-brachial index (ABI) is a screening tool for peripheral arterial disease (PAD). However, persons with normal ABI may still exhibit abnormalities in the physical examination of arterial system (PHEA)., Objective: In older persons from the PolSenior study, we aimed to assess the risk of total mortality associated with abnormalities in PHEA in the context of dichotomised ABI., Methods: We used data from the PolSenior survey and matched them with mortality information from the Polish Census Bureau. We obtained sociodemographic, medical history, and lifestyle data. The PHEA by a geriatrician included carotid, femoral, popliteal, posterior tibial and the dorsalis pedis arterial pulses, and auscultation of aorta, carotid, femoral, and renal arteries. Ankle-brachial index was tibial to brachial SBP ratio. We plotted the stratified Kaplan-Meier curves and used Cox's regression to assess the unadjusted and adjusted influence of PHEA result on time to death., Results: The mean (standard deviation, SD) age of 852 persons (46.7% women) was 74.7 (10.6) years. In the ABI < 0.9 group, the PHEA was not associated with mortality. However, in the ABI ≥ 0.9 group, both in unadjusted and adjusted (RHR; 95% CI: 1.08; 1.02-1.16, p = 0.01) Cox regression, PHEA greater by 1 score was associated with mortality. Presence of 4 or more PHEA abnormalities was raising the risk in the ABI ≥ 0.9 group to the level associated with ABI < 0.9., Conclusions: In the older persons with normal ABI, the greater number of abnormalities during physical examination of arteries may be indicative of higher risk of death., (© 2022. The Author(s).)

Background: Since the Russian invasion of Ukraine on Feb 24, 2022, more than 6 million Ukrainians, including hundreds of thousands of older people, have sought safety abroad. Older people generally have a higher burden of disease than younger people and the aim of our study was to estimate this burden in older Ukrainian refugees, given the potential financial and logistical impacts on the health-care systems of receiving countries., Methods: On May 20, 2022, we searched the official websites of the Polish Ministry of Digitisation for data on Ukrainian refugees who had applied between Feb 24, 2022, and May 19, 2022 for a Polish personal identification number (PESEL). We extracted the number of older people (ie, of pension age, which in Ukraine is 60 years or older for men, and 55 years or older for women). We calculated the percentage of older people among these PESEL applicants then extrapolated this percentage to two groups, for which population data had been extracted from UN, WHO, and Polish Border Guards websites: refugees who had crossed into Poland but had not applied for a PESEL and refugees who had fled to neighbouring countries other than Poland. Between April 4 and May 19, 2022, we searched the Ukrainian Ministry of Health official website for data on the prevalence and incidence of various diseases in the Ukrainian population of older people. We asked the Ukrainian Ministry of Health to confirm and expand on the website data, and thereby obtained annual data for 2010-17. The ministry did not supply tuberculosis statistics, so on May 21, 2022, we searched the Ukrainian Ministry of Health website and extracted the most recent tuberculosis data, which were for 2020. We then calculated the absolute prevalence and incidence of diseases in older refugees., Findings: As of May 19, 2022, 6·3 million Ukrainians had fled their country, including 3·5 million (56%) who had entered Poland. 1 114 418 people applied for a PESEL, including 109 985 older people (91 349 Ukrainian women aged 55 years or older and 18 636 Ukrainian men aged 60 or older). We estimated that the overall number of older Ukrainian refugees was 624 690. We estimated that these older refugees have a mean of 2·5 diseases each, the most frequent of which are cardiovascular diseases, followed by gastrointestinal, respiratory, musculoskeletal, and genitourinary diseases. We estimated that the expected absolute incidence is greatest for pulmonary disorders (71 689 diagnoses), followed by cardiovascular (49 327), ocular (24 100), musculoskeletal (20 367), and genitourinary (16 836) disorders. The estimated number of new diagnoses per year was 4578 for tuberculosis and 7827 for cancer., Interpretation: Our data indicate that the disease burden of older Ukrainian refugees is considerable. Although our estimates are only approximations, they provide a basis for predicting which areas of health care will most need to be reinforced to meet the challenge of the potential financial and logistical impacts on receiving countries., Funding: There was no funding source for this study., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The aim of our studies was to determine the influence of a low-frequency electromagnetic field (EMF) on the phagocytosis of latex beads (LBs) and the expression level of proteins/genes in the human monocytic macrophage Mono Mac 6 (MM6) cell line in in vitro conditions. Before phagocytosis assay cells were pre-stimulated with infectious agents such as lipopolysaccharide (LPS), Staphylococcal enterotoxin B (SEB), or the proliferatory agent phytohaemagglutinin (PHA), and then exposed to EMF (30 mT, 7 Hz, 3 h). The expression of cytoplasmic proteins like iPLA, cPLA, iNOS, NLR3/4, and Hsp70 involved in the immune response pathways to phagocytosed particles were evaluated with the usage of the Western blot analysis. mRNA encoding the iNOS protein was detected by reverse transcription PCR method. The most meaningful changes were observed for PLA2 and NLC4 proteins level and between iNOS protein expression and mRNA encoding iNOS protein amount. The EMF exposure exerted the strongest effect on iNOS encoding mRNA in cells pre-stimulated with LPS or SEB and phagocytosing LBs. The influence of EMF on phagocytosis was experimentally proved for the first time and there is a need for further investigations in term of the usage of EMF as a prospect, supportive therapy., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Frailty is a common geriatric syndrome that indicates homeostenosis and increased risk of disability and mortality. It is amenable to intervention when detected. Hence, screening frailty is of utmost importance to preserve quality-of-life and function in older age. Simpler Modified Fried Frailty Scale is a very practical frailty screening tool that has recently been introduced and has rooted from the original Fried Scale. It is developed in Turkish and has been shown to predict mortality in nursing home residents. Considering the variety of languages in Europe, it seems valid to adapt and validate this tool in different European languages. Thereby, it is expected that clinicians will have the possibility to screen for frailty more quickly and easily in their practice across many countries. This report is written to explain the details of the final consensus methodology suggested for Simpler Modified Fried Frailty Scale validation in order to guide and help the research teams in their studies., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: It seems that caregivers (CGs) may be a reliable source of information for determining health condition of seniors. This might be important for general practitioners (GPs) and facilitate them conducting comprehensive geriatric assessment (CGA). The objectives of our study were to: compare populations of older patients with and without CGs, characterise the group of CGs, establish whether CGs are aware of patients' deficiencies in areas of CGA., Methods: Patients aged at least 65 years underwent CGA using eight tools in GPs' practices in and around Krakow, Poland. Seniors were divided into two groups: with and without CGs. CGs filled in an authors' questionnaire on their data and assessed seniors in eight domains corresponding to the tests used in CGA. Patients with and without CGs were also compared in terms of CGA results and basic demographic and medical data. Subjective CGs' responses were compared with objective CGA results., Results: We conducted CGA on 438 senior patients. Two hundred fifty eight (59%) of them were classified as patients with CGs. Patients with CGs were older, less educated, more often lived in rural areas and were more frequently in a relationship (as all p < 0.05). In seniors with CGs, the results of frailty (p < 0.008) and insomnia scales (p = 0.049) were significantly worse. Mostly, CGs could properly assess seniors in basic and complex living activities and nutritional status. They were less precise in determining deficits like depressive tendency and insomnia., Conclusions: CGs' assessment of older patients can be a valuable source of information about seniors and can be helpful in diagnosing important health issues. CGs have difficulties when asked to properly assess depression and insomnia in the older adults they care for and their answers do not always correspond with the results of CGA. GPs should pay more attention to the needs of CGs themselves and provide them with the necessary knowledge about caring for older people., (© 2022. The Author(s).)

Sarcopenia and cardiovascular disease share some of the pathophysiologic mechanisms. Sarcopenia is likewise an important feature of frailty and the one potentially related to cardiovascular pathology. Previously, the relationship between arterial stiffness and frailty has been established. In this study, we conducted a systematic review and a meta-analysis of studies where the relationship between pulse wave velocity (PWV) and sarcopenia has been addressed. We included six cross-sectional studies that enrolled 5476 participants. Using the WebPlotDigitizer, RevMan5, and SAS 9.4, we extracted or calculated the summary statistics. We then calculated standardized mean differences (SMD) of PWV in the sarcopenic and non-sarcopenic participants. The pooled SMD was 0.73 (95% CI 0.39−1.08, p < 0.0001, I2 = 90%) indicating higher value in the sarcopenic subjects. The three studies that presented odds ratios for sarcopenia as a function of PWV homogenously indicated a greater probability of concomitant sarcopenia with higher values of PWV. Greater stiffness of the aorta is associated with sarcopenia. It is impossible to establish the causation. However, the plausible explanation is that increased stiffness may translate into or be an intermediary phenotype of common vascular and muscle damage. On the other hand, sarcopenia, which shares some of the inflammatory mechanisms with cardiovascular disease, may wind up the age-related large arterial remodeling.

Competing Interests: We declare no competing interests.

To assess the relationship between ankle-brachial index (ABI) and up to 10-year mortality in older individuals below and above the age of 80 years. In a multicenter survey of health status in the community dwelling subjects aged 55-59 and 65 + years in Poland, we assessed baseline medical history including risk-factors. We measured ABI, and serum creatinine, cholesterol, NT-proBNP, and interleukin-6 (IL-6) concentrations. We assessed mortality based on public registry. Between 2009 and 2019, 27.3% of 561 participants < 80 years, and 79.4% of 291 participants ≥ 80 years, died (p < 0.001); 67.8, 41.5, and 40.3% in the ABI groups < 0.9, 0.9-1.4, and > 1.4, respectively (p < 0.01). In the unadjusted Cox models, ABI was associated with mortality in the entire group, and < 80 years. In the entire group, analysis adjusted for age and sex showed mortality risk increased by 11% per year, and 50% with male sex. Mortality decreased by 37% per 1 unit ABI increase. In the group of people ≥ 80 years, only age was significantly associated with mortality (p < 0.001). In stepwise regression ABI < 0.9, male sex, active smoking, and NT-proBNP level were associated with risk of death < 80 years. In the ≥ 80 years old, mortality risk was associated with older age, and higher levels of IL-6, but not ABI. The ABI < 0.9 is associated with higher mortality in older people, but not among the oldest-old. In the oldest age group, age is the strongest predictor of death. In this age group, inflammageing is of importance., (© 2021. The Author(s).)

P u r p o s e: Oral health and diseases are significant components of general health. However, oral health-care remains at the lowest of older patients' priorities. The inability to obtain dental care can result in progression of dental disease, leading to a diminished quality of life and overall health. Teledentistry (TD) provides an opportunity to improve the quality of oral health services. The aim of our narrative review was to analyze the usefulness of teledentistry as a part of telemedicine to improve oral health in the elderly. Materials/Methods: The PubMed database search was done for: teledentistry, oral health, oral- health related diseases, elderly, older adults. R e s u l t s: The applicability of TD has been demonstrated from children to older adults. Older adults have many obstacles in getting oral health care, including low income, lack health insurance, frailty, anxiety, depression, mobility problems or other handicaps. Available data suggests that the usefulness of TD in the provision of oral care in elderly people living in residential aged care facilities. Moreover, TD procedures were found to be as accurate as traditional face-to-face dental examinations, they was cost-effective and well accepted among patients and caregivers. C o n c l u s i o n s: TD might be a very useful tool for professional education, improving access and patient satisfaction of dental care. However, such TD modes would be difficult to widely implementation in community-dwelling older people who cannot access dental care. The ongoing "Patient centric solution for smart and sustainable healthcare (ACESO)" project will add to the intelligent oral health solutions.

Introduction: Multimorbidity has been recognized as an important factor in geriatric medicine. However, its importance for other specialists is still to be fully appreciated., Objectives: The aim of the study was to assess the prevalence and patterns of multimorbidity in older patients drawn from the general population., Patients and Methods: The PolSenior was a nationwide, multicenter, cross-sectional survey of aged population in Poland. Questionnaire, physical examination, and laboratory data were gathered. Multimorbidity was defined as a coexistence of 2 and more chronic diseases or medical problems out of 17 identified. Factor analysis was employed to identify clusters of conditions., Results: Of 4588 patients, 51.9% were men; 640 were aged 55 to 59 years; 3948, ≥65 years; and 1757, ≥80 years. Multimorbidity depended on age and sex, and was diagnosed in 70.9% of those aged 55 to 59 years, 88.4% of those aged 65 to 79 years, and 93.9% of those aged ≥80 years. Only 8.5% of participants aged 55 to 59, 2.2% aged 65 to 79 years, and 0.9% aged ≥80 years had no diagnosis of chronic disease. Hypertension, metabolic diseases, and obesity predominated in those aged 55 to 59 and 65 to 79 years, whereas hypertension, eye disorders, and cognitive impairment prevailed in the oldest group. The highest likelihood of multimorbidity was found in the youngest participants who had stroke, kidney disease, cancer, or a composite of Parkinson disease / epilepsy; in 65-to-79-year-olds with a history of stroke; and in ≥80-year-olds with a history of stroke or heart failure., Conclusions: The age-specific analysis of clustering revealed differences in prevalence and patterns of comorbidities, which stresses the importance of individual approach to older patients.

Introduction: Hospitalization is associated with acute changes in sarcopenia status in older people, but the influencing factors are not fully understood. Pre-admission care dependency level as a risk factor has not yet been investigated., Objective: Evaluate if pre-admission care dependency level is an independent predictor of sarcopenia changes following hospitalization., Setting and Subjects: Data came from the Sarcopenia 9+ EAMA Project, a European prospective multi-centre study. For this study, 227 hospitalised older people were included from four different hospitals in Belgium, Spain and Poland, between 18 February 2019 and 5 September 2020., Methods: Sarcopenia status at admission and discharge were calculated using a combined score (desirability value) based on muscle mass (calf circumference), strength (grip) and function (walking speed). Ratio of admission to discharge status was the outcome (desirability ratio; 1.00 meaning no difference). Predictor variable was the pre-admission care dependency level, classified into three groups: independent older people living at home, dependent older people living at home and older people living in a care home. Linear regression models were applied, considering potential confounders., Results: Mean desirability ratio for dependent older people living at home ('middle dependent group') was lower (0.89) compared to independent older people (0.98; regression coefficient -0.09 [95% CI -0.16, -0.02]) and care home patients (1.05; -0.16 [95% CI -0.01, -0.31]). Adjusting for potential confounders or using another statistical approach did not affect the main results., Conclusion: Dependent older people living at home were at higher risk of deterioration in sarcopenia status following hospitalization. In-depth studies investigating causes and potential interventions of these findings are needed., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Frailty and cardiovascular disease share some of the pathophysiologic features. Our objective was to review and metaanalyse the available published evidence on the topic. We performed a comprehensive literature search for studies where pulse wave velocity (PWV) or carotid-ankle vascular index (CAVI) has been linked with frailty in older persons. Of the initial 362 abstracts, after the application of the PRISMA approach, 5 were analysed in detail. We calculated within-study and pooled standardised mean differences of aortic stiffness measures between frail and non-frail (0.62 [0.31-0.92], p < 0.0001, I 2  = 88%), and pre-frail and non-frail (0.32 [0.14-0.51], p = 0.0006, I 2  = 72%) groups. In two studies it was possible to extract directly or calculate based on published data the odds ratios for the concomitant frailty, associated in one case with CAVI greater by 1 m/s and in another with cfPWV >13 m/s, indicating greater probability of concomitant frailty given greater aortic stiffness. Across the studies, the prevalence of hypertension, diabetes mellitus, hyperlipidaemia, and smoking tended to increase from non-frail, to pre-frail, and frail groups, presenting a possibility of important confounding, but also a common pathophysiology. In conclusion, the pooled analysis of the published cross-sectional study results indicates a relation between aortic stiffness and frailty in older subjects. However, well designed prospective studies are needed to answer the questions of causality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

In this review, we discuss the pathophysiologic and management aspects of acute sarcopenia in relation to SARS-CoV-2 infection. COVID-19 is as a multi-organ infectious disease characterized by a severe inflammatory and highly catabolic status, influencing the deep changes in the body build, especially the amount, structure, and function of skeletal muscles which would amount to acutely developed sarcopenia. Acute sarcopenia may largely impact patients' in-hospital prognosis as well as the vulnerability to the post-COVID-19 functional and physical deterioration. The individual outcome of the COVID-19 and the degree of muscle mass and functional loss may be influenced by multiple factors, including the patient's general pre-infection medical and functional condition, especially in older adults. This paper gathers the information about how the SARS-CoV-2 hyper-inflammatory involvement exacerbates the immunosenescence process, enhances the endothelial damage, and due to mitochondrial dysfunction and autophagy, induces myofibrillar breakdown and muscle degradation. The aftermath of these acute and complex immunological SARS-CoV-2-related phenomena, augmented by anosmia, ageusia and altered microbiota may lead to decreased food intake and exacerbated catabolism. Moreover, the imposed physical inactivity, lock-down, quarantine or acute hospitalization with bedrest would intensify the acute sarcopenia process. All these deleterious mechanisms must be swiftly put to a check by a multidisciplinary approach including nutritional support, early physical as well cardio-pulmonary rehabilitation, and psychological support and cognitive training. The proposed holistic and early management of COVID-19 patients appears essential to minimize the disastrous functional outcomes of this disease and allow avoiding the long COVID-19 syndrome., (© 2021. The Author(s).)

Despite many studies, the question about the positive or negative influence of electromagnetic fields (EMF) on living organisms still remains an unresolved issue. To date, the results are inconsistent and hardly comparable between different laboratories. The observed bio-effects are dependent not only on the applied EMF itself, but on many other factors such as the model system tested or environmental ones. In an organism, the role of the defense system against external stressors is played by the immune system consisting of various cell types. The immune cells are engaged in many physiological processes and responsible for the proper functioning of the whole organism. Any factor with an ability to cause immunomodulatory effects may weaken or enhance the response of the immune system. This review is focused on a wide range electromagnetic fields as a possible external factor which may modulate the innate and/or adaptive immunity. Considering the existing databases, we have compiled the bio-effects evoked by EMF in particular immune cell types involved in different types of immune response with the common mechanistic models and mostly activated intracellular signaling cascade pathways., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Sarcopenia is a potentially reversible condition, which requires proper screening and diagnosis., Aims: To validate a Polish version of sarcopenia screening questionnaire (SARC-F), and assess its clinical performance., Methods: Cross-sectional validation study in community-dwelling subjects ≥ 65 years of age. Diagnosis of sarcopenia was based on the 2018 2nd European Working Group on Sarcopenia in Older People (EWGSOP2) consensus. Hand grip and 4-m gait speed were measured, and the Polish version of SARC-F was administered., Results: The mean (SD) age of 73 participants (21.9% men) was 77.8 (7.3) years. Seventeen participants (23.3%) fulfilled the EWGSOP2 criteria of sarcopenia, and 9 (12.3%) criteria for severe sarcopenia. Fourteen (19.2%) participants fulfilled the SARC-F criteria for clinical suspicion of sarcopenia. The Cronbach's alpha coefficient for internal was 0.84. With EWGSOP2 sarcopenia as a gold standard, the sensitivity of SARC-F was 35.3% (95% CI 14.2-61.7, p = 0.33), specificity was 85.7% (95% CI 73.8-93.6, p < 0.0001). The corresponding positive and negative predictive values were 42.9% (p = 0.79) and 81.4% (p < 0.0001), respectively. The probability of false-positive result was 14.3% (95% CI 6.4-26.2, p < 0.0001) and the probability of false-negative result was 64.7% (95% CI 38.3-85.8, p = 0.33). Overall the predictive power of SARC-F was low (c-statistic 0.64)., Discussion: SARC-F is currently recommended for sarcopenia case finding in general population of older adults. However, its sensitivity is low, despite high specificity., Conclusions: At present SARC-F is better suited to rule out sarcopenia then to case-finding. Further refinement of screening for sarcopenia with the use of SARC-F seems needed.

Purpose: In 2018, the SARCUS working group published a first article on the standardization of the use of ultrasound to assess muscle. Recommendations were made for patient positioning, system settings and components to be measured. Also, shortcomings in knowledge were mentioned. An important issue that still required standardization was the definition of anatomical landmarks for many muscles., Methods: A systematic search was performed in Medline, SCOPUS and Web of Sciences looking for all articles describing the use of ultrasound in the assessment of muscle not described in the first recommendations, published from 01/01/2018 until 31/01/2020. All relevant terms used for older people, ultrasound and muscles were used., Results: For 39 muscles, different approaches for ultrasound assessment were found that likely impact the values measured. Standardized anatomical landmarks and measuring points were proposed for all muscles/muscle groups. Besides the five already known muscle parameters (muscle thickness, cross-section area, pennation angle, fascicle length and echo-intensity), four new parameters are discussed (muscle volume, stiffness, contraction potential and microcirculation). The former SARCUS article recommendations are updated with this new information that includes new muscle groups., Conclusions: The emerging field of ultrasound assessment of muscle mass only highlights the need for a standardization of measurement technique. In this article, guidelines are updated and broadened to provide standardization instructions for a large number of muscles.

Purpose: The United Nations (UN) has published a Policy Brief on the impact of the Coronavirus Disease 2019 (COVID-19) that identifies policies and responses to protect older adults. Our objective was to summarize actions, health policies and clinical guidelines adopted by six European countries (Belgium, France, Italy, Poland, Spain and United Kingdom) during the pandemic, and to assess the impact of national policies on reducing adverse effects of the COVID-19 pandemic in older populations., Methods: Reports by geriatricians on the measures and actions undertaken by governmental institutions in each country between March and July 2020, as well as the role of primary care during the pandemic, covered three areas: (a) general health strategies related to the pandemic; (b) impact of COVID-19 on health inequity; and (c) initiatives and challenges for the COVID-19 pandemic and beyond., Results: In the six countries, COVID-19 mortality in nursing homes ranged from 26 to 66%. Although all countries endorsed the World Health Organization general recommendations, the reports identified the lack of harmonized European guidelines and policies for nursing homes, with competencies transferred to national (or regional) governments. All countries restricted visits in nursing homes, but no specific action plans were provided. The role of primary care was limited by the centralization of the crisis in hospital settings., Conclusions: The older population has been greatly affected by COVID-19 and by the policies initiated to control its spread. The right to health and dignity are transgenerational; chronological age should not be the sole criterion in policy decisions.

The 2019 EuGMS Congress "Evidence-Based Medicine in Geriatrics" was held in Krakow, Poland, and attended by over 1600 participants from 64 different countries. A summary and reflection on the congress was presented in the Closing Ceremony by European Academy for Medicine of Aging graduates, and summarised in this article. Keynote lectures, 'state of the art' sessions and symposia presented the evidence relating to different age-related conditions, their prevention, management and treatments. Hot topic areas included frailty and multimorbidity, and evidence-based attempts to address these conditions at different life stages. The field of geriatrics represents unique challenges for evidence-based medicine practice. There is much research going on. Clear leadership is needed to facilitate consensus agreements on standard definitions, methods and relevant outcomes, in collaboration with older people themselves, to maximise the opportunities and benefits of doing this research, and benefiting our patients and society at large.

Introduction: Malnutrition and nutrition-related diseases are associated with hospital admissions, disability, institutionalization, and mortality in older people. Specialists in Geriatric Medicine and nutrition evaluate nutritional status as part of the comprehensive geriatric assessment; however, malnutrition still remains under-recognized and under-managed. Our survey explored nutrition assessment approaches used in daily clinical practice by geriatricians across Europe., Methods: A 19-item survey on methods and instruments for malnutrition assessment in geriatric settings, and details of any national guidelines, was sent to 40 postgraduate fellows of the European Academy of Medicine of Aging (EAMA, 2017-2019 class)., Results: Thirty-six of the 40 eligible EAMA participants, representing 14 European countries, responded. In clinical practice, MNA and MNA-SF were most frequently used for screening (44.1%, 52.9%, respectively) and diagnosing (45.7%, 40.0%) malnutrition. Weight loss (n = 36, 100%), body mass index (n = 30, 85.7%), and low energy/food intake (n = 27, 77.1%) were the most frequent clinical variables considered. The absolute and relative amount of weight loss, and over what time period, varied widely. These routinely considered clinical factors contribute to validated GLIM, ASPEN-AND and ESPEN criteria for diagnosis of malnutrition, but these criteria were seldom used (GLIM = 0%, ASPEN = 0%; n = 9, ESPEN = 25.7%). National guidelines were available in 9 of the 14 countries, and generally recommended MNA and MNA-SF for community-dwelling and hospitalized older patients. Albumin was often suggested as a nutritional marker., Conclusions: Nutritional assessment is systematically performed in geriatrics; but differs widely among geriatricians and countries. Harmonizing guidelines with the new international consensus might provide best-evidence care for older people across Europe., Competing Interests: Declaration of Competing Interest All authors declare they do not have any financial or personal relationships with other people or organizations that could inappropriately influence their work., (Copyright © 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Cardiovascular disease burden increases with the increasing age of populations. Also, with increasing longevity, some individuals are ageing along an unfavourable path developing frailty syndrome. Epidemiologic studies indicate that frailty is overrepresented among the persons with cardiovascular disease. On the other hand, frail subjects tend to be burdened with cardiovascular disease to a greater degree than their biologically better-off peers. Hypertension, diabetes, and obesity, especially abdominal, and at least some other risk factors appear to be shared between frailty and cardiovascular disease. The probable common underlying pathophysiologic feature is inflammation and associated phenomena, possibly having its root in the inflammageing. We discuss these issues based on the results of original studies, comprehensive literature reviews, and metaanalyses, by hundreds of dedicated researchers worldwide.

Purpose: To report the most important messages of the 2018 EuGMS Congress in Berlin., Methods: Review based on an on-site attendance in the sessions by the European Academy for Medicine of Aging graduates., Results: The 14th Congress of the European Geriatric Medicine Society which took place in Berlin, Germany, from 10 to 12 October 2018, addressed the issue of challenges and opportunities associated with a fast changing modern world. Covering among other topics social issues, new technologies and the much-awaited new European definition of sarcopenia, the meeting streamed with important information., Conclusions: Attended by more than 1800 participants from Europe and from across the world, it was one of the most successful geriatric events in 2018. In the following text, in preparation to the next, 15th Congress in Kraków, Poland, we briefly describe the highlights of the Berlin Congress., (© 2019. The Author(s).)

Background: Prevalence of peripheral arterial disease increases with age and is related to increased morbidity and mortality. The clinical diagnosis includes the measurement of ankle-brachial index (ABI)., Aims: To check the prevalence of abnormal ABI, and the value of physical examination of arterial system in detection of ABI < 0.9., Methods: We performed subgroup analysis of patients included in the PolSenior survey. We measured ABI, performed physical examination of arterial system, assessed laboratory and questionnaire factors related to atherosclerosis. Participants were divided according to ABI strata of < 0.9, 0.9-1.4 and > 1.4. Clinical score of abnormalities on physical examination was proposed. Using logistic regression, we obtained areas under the curve (AUC)., Results: The mean age of 844 participants (53.3% men) was 74.7 (10.6) years. ABI < 0.9 was found in 20.3% participants and it was linked to history of myocardial infarction, hypertension and renal failure. In the entire group, 72.4% of subjects declared, that they were able to walk a distance of 200 m without interruption. Higher clinical score was associated with lower ABI. Full physical examination (AUC = 0.67) followed by examination of lower extremities (AUC = 0.65) showed strongest diagnostic value for PAD based on ABI. Neither ABI nor clinical examination was a good predictor of the inability to walk 200 meters without difficulties., Discussion/conclusions: Full clinical examination, only moderately, adds to detection of PAD. The ability to walk 200 m is not a good measure of PAD in older subjects.

Background: Since its introduction by Hodkinson in 1972, Abbreviated Mental Test Score (AMTS) and its English and other language versions have been widely used in research and clinical practice alike. However, whether the various versions of AMTS yield equivalent information has never been tested., Methods: We performed cross-sectional assessment of inpatients aged 65+ years with seven AMTS versions and the Mini-Mental State Examination (MMSE) after correction for age and education (MMSEc). We used the MMSEc cut-off score of < 24 as comparator and fitted linear regression models from which we obtained the receiver operating characteristics, and further compared the c-statistics obtained for each version of AMTS. We used Spearman's correlation to check the relation between different AMTS versions., Results: The mean (SD) age of 72 (52.8% women) patients was 76.2 (7.6) years. The average time spent on education was 11.3 (3.5) years. The AMTS score across versions varied between 7.4 (2.0) and 8.2 (1.7). The MMSE averaged 24.1 (4.6) and the MMSEc averaged 25.2 (4.1). We found that the c-statistic across AMTS versions with dichotomised MMSEc as comparator ranged from 0.83 to 0.85 and did not significantly differ from the c-statistic of 0.87 for original AMTS (all p > 0.16). We found AMTS versions to be significantly correlated (all r between 0.83 and 0.99, all p < 0.0001)., Conclusions: We found AMTS to be a reliable and useful tool in the screening for possible cognitive impairment. This seems to be true irrespective of whether we use the original test or any of its studied modifications.

Purpose: Measurement of muscle mass is paramount in the screening and diagnosis of sarcopenia. Besides muscle quantity however, also quality assessment is important. Ultrasonography (US) has the advantage over dual-energy X-ray absorptiometry (DEXA) and bio-impedance analysis (BIA) to give both quantitative and qualitative information on muscle. However, before its use in clinical practice, several methodological aspects still need to be addressed. Both standardization in measurement techniques and the availability of reference values are currently lacking. This review aims to provide an evidence-based standardization of assessing appendicular muscle with the use of US., Methods: A systematic review was performed for ultrasonography to assess muscle in older people. Pubmed, SCOPUS and Web of Sciences were searched. All articles regarding the use of US in assessing appendicular muscle were used. Description of US-specific parameters and localization of the measurement were retrieved., Results: Through this process, five items of muscle assessment were identified in the evaluated articles: thickness, cross-sectional area, echogenicity, fascicle length and pennation angle. Different techniques for measurement and location of measurement used were noted, as also the different muscles in which this was evaluated. Then, a translation for a clinical setting in a standardized way was proposed., Conclusions: The results of this review provide thus an evidence base for an ultrasound protocol in the assessment of skeletal muscle. This standardization of measurements is the first step in creating conditions to further test the applicability of US for use on a large scale as a routine assessment and follow-up tool for appendicular muscle., (© 2018. European Geriatric Medicine Society.)

Background: In hospital settings, delirium affects as many as 50% of older patients, aggravating their symptoms and worsening their condition, and therefore increasing the risk of in-hospital complications and death. The aim of this study is to assess the efficacy of structured, non-pharmacological care, delivered to older hospitalised patients by trained volunteers (students of medical fields), on the reduction of incidence of adverse health-related outcomes., Methods/design: This trial will be a randomised, investigator-blind, controlled trial conducted in an internal medicine and geriatric ward in Poland. We aim to include 416 patients who are 70 years of age and have been hospitalised for medical reasons. Eligible patients will be randomised 1:1 to receive structured, non-pharmacological care delivered by students of medicine, psychology and nursing, together with standard medical treatment or standard medical care alone. The protocol of interventions has been designed to cover nine main risk factors for delirium, with the scope of multidisciplinary interventions being individualised and tailored. The protocol will be aimed at immobilisation, vision and hearing impairment, cognitive impairment and disorientation, stress and anxiety, sleep-wake cycle disturbances, dehydration and malnutrition, and pain. A structured evaluation of patients' cognition, mood, anxiety and functional performance is planned to be carried out twice, on the day of group allocation and at discharge; structured screening assessment for delirium will be conducted daily using the Confusion Assessment Method. The primary outcome will be the incidence of delirium in hospital; secondary outcomes will be in-hospital changes in cognition, mood and anxiety, and functional status, occurrence of falls and death., Discussion: Delirium prevention programmes are being introduced worldwide. A particular novelty of our project, however, is that invitations for voluntary work with older patients at risk for delirium will be addressed to medical students. With the use of the service learning method, the students will shape their attitudes, increase their knowledge and understanding of hospital care, and master competencies to work within interdisciplinary teams, which establishes the originality and practicality of the project., Trial Registration: Polish Science Database, 317484 . Registered on 23 October 2016.