Search

Abstract Background Populations are ageing globally and Low- and Middle-Income Countries (LMICs) are experiencing the fastest rates of demographic change. Few studies have explored the burden of frailty amongst older people in hospital in LMICs, where healthcare services are having to rapidly adapt to align with the needs of older people. This study aimed to measure the prevalence of frailty amongst older people admitted to hospital in Tanzania and to explore their demographic and clinical characteristics. Methods This study had a prospective observational design. Over a six-month period, all adults ≥ 60 years old admitted to medical wards in four hospitals in northern Tanzania were invited to participate. They were screened for frailty using the Clinical Frailty Scale (CFS) and the Frailty Phenotype (FP). Demographic and clinical characteristics of interest were recorded in a structured questionnaire. These included the Barthel Index, the Identification of Elderly Africans Instrumental Activities of Daily Living (IADEA-IADL) and Cognitive (IDEA-Cog) screens, the EURO-D depression scale and Confusion Assessment Method. Results 540 adults aged ≥ 60 were admitted, and 308 completed assessment. Frailty was present in 66.6% using the CFS and participants with frailty were significantly older, with lower levels of education and literacy, greater disability, greater comorbidity, poorer cognition and higher levels of delirium. Using the FP, 57.0% of participants were classed as frail though a majority of participants (n = 159, 51.6%) could not be classified due to a high proportion of missing data. Conclusions This study indicates that the prevalence of frailty on medical wards in northern Tanzania is high according to the CFS. However, the challenges in operationalising the FP in this setting highlight the need for future work to adapt frailty screening tools for an African context. Future investigations should also seek to correlate frailty status with long-term clinical outcomes after admission in this setting.

Background: International medical graduates (IMGs) make up approximately one fifth of all licensed doctors in the UK. [1]NHS experience has been desirable for doctors from Myanmar/Burma for many years. Since the military coup took place in February 2021, there has been significant violence against healthcare professionals resulting in doctors moving to the UK to be able to continue and enhance their careers. [2]The aim of this study was to outline the Myanmar/Burma Doctors' Journey after arriving in the UK until accomplishing GMC registration and securing NHS positions. We also aimed to explore the integration and experiences of doctors from Myanmar/Burma joining the NHS between February 2021 and December 2023. Method: In October 2023, an electronic survey was sent via personalised email to 294 Myanmar doctors in the UK. The survey was anonymous and included a consent process. In addition to demographic and background data, the survey contained multiple choice and Likert style questions and took between 20-30 minutes to complete. Data were analysed using Microsoft Excel. Results: Response rate to the survey was 13% (38/294). Most of the respondents were female (65%) and the majority were between the ages of 24–29 (64.9%). 92% had obtained their primary medical qualification between 2015–2020.The vast majority (94.6%) of doctors went through the PLAB pathway to obtain GMC registration. This includes passing two exams as well as an English language test. The average time to obtain GMC registration from date of entry to the UK was 5.89 months and to secure an NHS job was 10.34 months. More than 50% of the respondents applied for over 50 jobs before securing their first position. 63.1% of doctors were employed as either junior clinical fellows or trust grade doctors.Language barriers, adaptation to the UK system and a sense of belonging were the top three challenges reported. Whilst many doctors felt their employing trusts recognised wellbeing to some degree, 29% felt their wellbeing had been negatively impacted since starting work. Alarmingly, 23.5% of doctors felt that they had experienced some form of discrimination since starting work. A quote shared in the survey to illustrate this:‘I feel so small working among the local people…..I was not treated as part of the team.’ Conclusions: The journey to acquisition of GMC registration takes time and cost. For doctors from Myanmar/Burma, these pressures are in addition to the stressors generated from being displaced from friends, family and colleagues.This study highlights the importance of wellbeing for IMGs new to the NHS. We recommend NHS trusts explore wellbeing resources, utilise local support services and build a culture of care for IMGs. It is important staff awareness and training on discrimination is prioritised and the staff are empowered to raise concerns. Lastly, regular supervision and support for pathways such as CREST are important to aid integration, professional development and career progression.

COVID-19 has underlined the critical importance of bringing biosocial and biopsychosocial approaches to pre-health education. Given the striking social inequalities that the pandemic has both exposed and exacerbated, we argue that bridging between the biomedical and social sciences with such approaches is now more appropriate and urgently needed than ever. We therefore call for the re-socialization of pre-health education by teaching to develop socio-structural competencies alongside physical and biological science knowledge. We suggest that community partnerships, which address local inequalities and their global interdependencies, should be encouraged as an essential element in all pre-health education. Educators should also support such partnerships as opportunities for students who come from more minoritized and impoverished social backgrounds to see their own social knowledge–including community-based knowledge of health-injustices revealed by the pandemic–as the basis of biopsychosocial expertise. By prioritizing this reconceptualization of pre-health education, we can empower future health workers to prepare more adequately for future health crises in ways that are socially aware and structurally transformative.

Symptoms of psychological distress and disorder have been widely reported in people under quarantine during the COVID-19 pandemic; in addition to severe disruption of peoples’ daily activity and sleep patterns. This study investigates the association between physical-activity levels and sleep patterns in quarantined individuals. An international Google online survey was launched in April 6th, 2020 for 12-weeks. Forty-one research organizations from Europe, North-Africa, Western-Asia, and the Americas promoted the survey through their networks to the general society, which was made available in 14 languages. The survey was presented in a differential format with questions related to responses “before” and “during” the confinement period. Participants responded to the Pittsburgh Sleep Quality Index (PSQI) questionnaire and the short form of the International Physical Activity Questionnaire. 5056 replies (59.4% female), from Europe (46.4%), Western-Asia (25.4%), America (14.8%) and North-Africa (13.3%) were analysed. The COVID-19 home confinement led to impaired sleep quality, as evidenced by the increase in the global PSQI score (4.37 ± 2.71 before home confinement vs. 5.32 ± 3.23 during home confinement) (p < 0.001). The frequency of individuals experiencing a good sleep decreased from 61% (n = 3063) before home confinement to 48% (n = 2405) during home confinement with highly active individuals experienced better sleep quality (p < 0.001) in both conditions. Time spent engaged in all physical-activity and the metabolic equivalent of task in each physical-activity category (i.e., vigorous, moderate, walking) decreased significantly during COVID-19 home confinement (p < 0.001). The number of hours of daily-sitting increased by ~2 hours/days during home confinement (p < 0.001). COVID-19 home confinement resulted in significantly negative alterations in sleep patterns and physical-activity levels. To maintain health during home confinement, physical-activity promotion and sleep hygiene education and support are strongly warranted.

Background: Whilst there is literature on the impact of SARS viruses in the severely immunosuppressed, less is known about the link between routine immunosuppressant use and outcome in COVID-19. Consequently, guidelines on their use vary depending on specific patient populations. Methods: The study population was drawn from the COPE Study (COVID-19 in Older People), a multicentre observational cohort study, across the UK and Italy. Data were collected between 27 February and 28 April 2020 by trained data-collectors and included all unselected consecutive admissions with COVID-19. Load (name/number of medications) and dosage of immunosuppressant were collected along with other covariate data. Primary outcome was time-to-mortality from the date of admission (or) date of diagnosis, if diagnosis was five or more days after admission. Secondary outcomes were Day-14 mortality and time-to-discharge. Data were analysed with mixed-effects, Cox proportional hazards and logistic regression models using non-users of immunosuppressants as the reference group. Results: In total 1184 patients were eligible for inclusion. The median (IQR) age was 74 (62–83), 676 (57%) were male, and 299 (25.3%) died in hospital (total person follow-up 15,540 days). Most patients exhibited at least one comorbidity, and 113 (~10%) were on immunosuppressants. Any immunosuppressant use was associated with increased mortality: aHR 1.87, 95% CI: 1.30, 2.69 (time to mortality) and aOR 1.71, 95% CI: 1.01–2.88 (14-day mortality). There also appeared to be a dose–response relationship. Conclusion: Despite possible indication bias, until further evidence emerges we recommend adhering to public health measures, a low threshold to seek medical advice and close monitoring of symptoms in those who take immunosuppressants routinely regardless of their indication. However, it should be noted that the inability to control for the underlying condition requiring immunosuppressants is a major limitation, and hence caution should be exercised in interpretation of the results. Plain Language Summary Regular Use of Immune Suppressing Drugs is Associated with Increased Risk of Death in Hospitalised Patients with COVID-19 Background: We do not have much information on how the COVID-19 virus affects patients who use immunosuppressants, drugs which inhibit or reduce the activity of the immune system. There are various conflicting views on whether immune-suppressing drugs are beneficial or detrimental in patients with the disease. Methods: This study collected data from 10 hospitals in the UK and one in Italy between February and April 2020 in order to identify any association between the regular use of immunosuppressant medicines and survival in patients who were admitted to hospital with COVID-19. Results: 1184 patients were included in the study, and 10% of them were using immunosuppressants. Any immunosuppressant use was associated with increased risk of death, and the risk appeared to increase if the dose of the medicine was higher. Conclusion: We therefore recommend that patients who take immunosuppressant medicines routinely should carefully adhere to social distancing measures, and seek medical attention early during the COVID-19 pandemic.

Objective: During the COVID-19 pandemic the continuation or cessation of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) has been contentious. Mechanisms have been proposed for both beneficial and detrimental effects. Recent studies have focused on mortality with no literature having examined length of hospital stay. The aim of this study was to determine the influence of ACEi and ARBs on COVID-19 mortality and length of hospital stay. Methods: COPE (COVID-19 in Older People) is a multicenter observational study including adults of all ages admitted with either laboratory or clinically confirmed COVID-19. Routinely generated hospital data were collected. Primary outcome: mortality; secondary outcomes: Day-7 mortality and length of hospital stay. A mixed-effects multivariable Cox’s proportional baseline hazards model and logistic equivalent were used. Results: 1371 patients were included from eleven centres between 27th February to 25th April 2020. Median age was 74 years [IQR 61–83]. 28.6% of patients were taking an ACEi or ARB. There was no effect of ACEi or ARB on inpatient mortality (aHR = 0.85, 95%CI 0.65–1.11). For those prescribed an ACEi or ARB, hospital stay was significantly reduced (aHR = 1.25, 95%CI 1.02–1.54, p = 0.03) and in those with hypertension the effect was stronger (aHR = 1.39, 95%CI 1.09–1.77, p = 0.007). Conclusions: Patients and clinicians can be reassured that prescription of an ACEi or ARB at the time of COVID-19 diagnosis is not harmful. The benefit of prescription of an ACEi or ARB in reducing hospital stay is a new finding.

Introduction This protocol describes an observational study which set out to assess whether frailty and/or multimorbidity correlates with short-term and medium-term outcomes in patients diagnosed with COVID-19 in a European, multicentre setting.Methods and analysis Over a 3-month period we aim to recruit a minimum of 500 patients across 10 hospital sites, collecting baseline data including: patient demographics; presence of comorbidities; relevant blood tests on admission; prescription of ACE inhibitors/angiotensin receptor blockers/non-steroidal anti-inflammatory drugs/immunosuppressants; smoking status; Clinical Frailty Score (CFS); length of hospital stay; mortality and readmission. All patients receiving inpatient hospital care >18 years who receive a diagnosis of COVID-19 are eligible for inclusion. Long-term follow-up at 6 and 12 months is planned. This will assess frailty, quality of life and medical complications.Our primary analysis will be short-term and long-term mortality by CFS, adjusted for age (18–64, 65–80 and >80) and gender. We will carry out a secondary analysis of the primary outcome by including additional clinical mediators which are determined statistically important using a likelihood ratio test. All analyses will be presented as crude and adjusted HR and OR with associated 95% CIs and p values.Ethics and dissemination This study has been registered, reviewed and approved by the following: Health Research Authority (20/HRA1898); Ethics Committee of Hospital Policlinico Modena, Italy (369/2020/OSS/AOUMO); Health and Care Research Permissions Service, Wales; and NHS Research Scotland Permissions Co-ordinating Centre, Scotland. All participating units obtained approval from their local Research and Development department consistent with the guidance from their relevant national organisation.Data will be reported as a whole cohort. This project will be submitted for presentation at a national or international surgical and geriatric conference. Manuscript(s) will be prepared following the close of the project.

Summary: Background: The COVID-19 pandemic has placed unprecedented strain on health-care systems. Frailty is being used in clinical decision making for patients with COVID-19, yet the prevalence and effect of frailty in people with COVID-19 is not known. In the COVID-19 in Older PEople (COPE) study we aimed to establish the prevalence of frailty in patients with COVID-19 who were admitted to hospital and investigate its association with mortality and duration of hospital stay. Methods: This was an observational cohort study conducted at ten hospitals in the UK and one in Italy. All adults (≥18 years) admitted to participating hospitals with COVID-19 were included. Patients with incomplete hospital records were excluded. The study analysed routinely generated hospital data for patients with COVID-19. Frailty was assessed by specialist COVID-19 teams using the clinical frailty scale (CFS) and patients were grouped according to their score (1–2=fit; 3–4=vulnerable, but not frail; 5–6=initial signs of frailty but with some degree of independence; and 7–9=severe or very severe frailty). The primary outcome was in-hospital mortality (time from hospital admission to mortality and day-7 mortality). Findings: Between Feb 27, and April 28, 2020, we enrolled 1564 patients with COVID-19. The median age was 74 years (IQR 61–83); 903 (57·7%) were men and 661 (42·3%) were women; 425 (27·2%) had died at data cutoff (April 28, 2020). 772 (49·4%) were classed as frail (CFS 5–8) and 27 (1·7%) were classed as terminally ill (CFS 9). Compared with CFS 1–2, the adjusted hazard ratios for time from hospital admission to death were 1·55 (95% CI 1·00–2·41) for CFS 3–4, 1·83 (1·15–2·91) for CFS 5–6, and 2·39 (1·50–3·81) for CFS 7–9, and adjusted odds ratios for day-7 mortality were 1·22 (95% CI 0·63–2·38) for CFS 3–4, 1·62 (0·81–3·26) for CFS 5–6, and 3·12 (1·56–6·24) for CFS 7–9. Interpretation: In a large population of patients admitted to hospital with COVID-19, disease outcomes were better predicted by frailty than either age or comorbidity. Our results support the use of CFS to inform decision making about medical care in adult patients admitted to hospital with COVID-19. Funding: None.

Physiological effects of psychological stress and infection in mothers can increase the incidence of anxiety and psychiatric diseases in offsprings and in subsequent generation. Here, Miklos Toth and colleagues show that intergenerational inheritance of neurological traits is propagated across multiple generations independently by parallel non-genetic mechanisms involving independent segregation of epigenetic specific loci.

Older adults undergoing vascular surgery are particularly vulnerable to adverse outcomes by virtue of their vascular risk factors and medical comorbidities. This study aimed to determine the impact of daily medical liaison for patients aged 65 years and older admitted to a regional vascular surgery centre. This was a descriptive before-and-after study concerning 375 patients. The primary outcome measure was length of stay (LOS). Following intervention, we identified a reduction in mean LOS in the sample from 10.75 to 7.95 days (p = 0.635, 95% Confidence Interval [CI] 0–5 days) with a statistically significant reduction in mean LOS for “stranded” patients admitted for more than seven days (mean 7.84 days reduction, p = 0.025, 95% CI for mean difference, 1.5 to 14 days). These patients did not display elevated 30-day readmission rates (12/60 to 8/72, p = 0.156, 95% CI −3% to 21%). A non-significant reduction in postoperative complications was seen in all patients in the post-intervention cohort (1.09 to 0.86 per person, p = 0.181, 95% CI −0.11 to 0.56), reaching statistical significance in emergency vascular admissions (1.81 to 0.97 complications per person, p = 0.01, mean difference = 0.84, 95% CI 0.21–1.46). This study demonstrated reduced LOS and complications in selected older patients admitted under vascular surgery after the introduction of a daily medical liaison model. These data are amongst the first to reproduce randomised controlled trial findings in a non-trial setting. Subgroup analysis indicates that patients admitted with acute pathology and those with long LOS may benefit most from medical liaison where resources are finite.

Marine Protected Areas (MPAs) are known to contribute toward the conservation of marine biodiversity, particularly targeted fishery species. Snapper Chrysophrys auratus are an important recreational and commercial fish species in New South Wales (NSW), Australia, and despite fishery management for this species, they are considered “growth overfished” in this region. To assess how C. auratus respond to the implementation of an MPA with several no-take and partially protected areas in temperate NSW, we monitored their populations over a decade (2006–2017) using baited remote underwater video systems (BRUVs). Surveys were conducted in the Port Stephens-Great Lakes Marine Park with BRUVs deployed on rocky reefs in depths of 20–50 m. Long term seasonal sampling (winter vs. summer) was undertaken at two locations (Broughton and Fingal Island), and changes in C. auratus abundance prior to, and 8 years after zoning implementation, were assessed between these two locations. In total, we sampled five no-take areas within the marine park and five comparative nearby partially protected fished areas and three sites located outside the marine park boundaries. The most pronounced changes in abundance and size structure for C. auratus were observed in the Broughton Island no-take area where numbers increased almost 3-fold (2.91 times) over 8 years of protection. Relative abundance showed seasonal variation at two locations, and we consistently recorded increasing abundance within no-take areas at Broughton and Fingal Island compared to nearby sites open to fishing. Surveys across the five no-take areas found a significant increase in the abundance of C. auratus, whilst the five partially-protected locations in the marine park still recorded higher abundances than sites outside the marine park. In addition, length measurements from stereo-BRUVS indicated that C. auratus were significantly larger in no-take areas compared to partially-protected areas in the marine park and sites outside the marine park. This study demonstrates how the implementation of the marine park and the protection afforded by no-take and partially-protected areas provides refuge for this important fishery targeted species.

LRRK2 mutations produce end-stage Parkinson’s disease (PD) with reduced nigrostriatal dopamine, whereas, asymptomatic carriers have increased dopamine turnover and altered brain connectivity. LRRK2 pathophysiology remains unclear, but reduced dopamine and mitochondrial abnormalities occur in aged G2019S mutant knock-in (GKI) mice. Conversely, cultured GKI neurons exhibit increased synaptic transmission. We assessed behavior and synaptic glutamate and dopamine function across a range of ages. Young GKI mice exhibit more vertical exploration, elevated glutamate and dopamine transmission, and aberrant D2-receptor responses. These phenomena decline with age, but are stable in littermates. In young GKI mice, dopamine transients are slower, independent of dopamine transporter (DAT), increasing the lifetime of extracellular dopamine. Slowing of dopamine transients is observed with age in littermates, suggesting premature ageing of dopamine synapses in GKI mice. Thus, GKI mice exhibit early, but declining, synaptic and behavioral phenotypes, making them amenable to investigation of early pathophysiological, and later parkinsonian-like, alterations. This model will prove valuable in efforts to develop neuroprotection for PD.

This article draws on two surveys of international students in Sydney and Melbourne, undertaken in 2019 and during the 2020 COVID-19 lockdowns. Using the concept of bounded agency, we identify how the challenges of living in one of the world's most expensive rental housing markets impact students' perceptions of their academic attainment. We find housing insecurity, unaffordability and condition, amplified by financial stress, contribute significantly to student anxiety about their studies. These relationships differ by student background and education. We argue students' agency to meet their educational ambitions in Australia is constrained by the cost of housing and the housing choices they consequently make to mitigate financial stress. Our findings suggest the importance of 'town' or non-institutional aspects of the international student experience on their satisfaction and academic outcomes. We call for further research to explore these relationships in other global contexts.

Housing is a major concern for many international students. This is especially so in those countries where students are mostly dependent on the private market for their accommodation. Australia is one such country, and is one of the world's major destinations for international students. This article analyses governmental failure to address problems relating to international student housing affordability and conditions. Using theory on 'policy inaction' to frame the analysis, we draw on 20 interviews with policy stakeholders to explain the Australian government's reliance on: (1) market-based housing provision for international students, and (2) a longstanding policy preference not to provide support. Interviewees were widely critical of the lack of action to address international student housing problems and understood inaction in relation, rather than in opposition, to the dominance of market-based action in housing and higher education. However, analysis of stakeholder perspectives also illuminates how policy-making "action" benefiting some emerges as "inaction" for others left behind or overlooked by the status quo. The interview data points to the need for government to overhaul its policy framework, and in doing so, to collaborate with higher education providers in revising the market-based regulatory approach. The main implications for theory and policy are discussed.