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Due to population ageing, the number of older and frail patients with cardiovascular disease is increasing. In the current guidelines of the European Society of Cardiology specific recommendations for this older population are missing or scarce, probably due to limited evidence concerning diagnosis and treatment of cardiovascular disease in older patients. Moreover, recommendations on shared decision making, palliative care and advanced care planning are also essential in these guidelines. In this article we evaluate the current European of Society of Cardiology guidelines (2013–2020) to determine whether specific recommendations for older patients have been included.

Background: In the Netherlands, it is customary to discuss directives regarding resuscitation, intubation, and ICU-admission with patients and/or their relatives upon hospital-admission. The outcome of this discussion is documented in a code status. Ideally, these advance care planning (ACP)-related decisions are made by a patient (and/or their relatives) and a professional together in a shared decision-making (SDM) process, to improve patient satisfaction and prevent undesired care. Given the bad outcomes in older COVID-19 patients, it is particularly important to discuss the code status upon admission. This study aims to describe the practice of SDM regarding code status during the COVID-pandemic. Specific aims were to find out to what extend patients took part in this decision-making process and whether all key elements of SDM for a shared decision were documented in medical reports. Methods: In this retrospective cohort study, we included COVID-19 patients aged 70 years and older, admitted to two large teaching hospitals in the Netherlands, during the first months of the COVID-19 pandemic in 2020. Data about code status and the decision-making process were extracted from electronic healthcare records. Results: Code status was documented for 274 of 275 included patients. Patient participation in the decision-making process was described in 48%. In 19% all key elements of shared decision-making have been described. Key elements of SDM were defined as the presence of a completed code status form, the presence of clinical notes showing that both patient’s wishes and values and the opinion of the healthcare professional about the predicted outcome was taken into consideration and clinical notes of a patient–healthcare professional interaction during the admission. Conclusion: Our results show that a proper SDM process regarding code status is possible, even in hectic times like the COVID-19-pandemic. However, shared decision-making was not common practice in older patients with COVID-19 regarding code status (an ACP-related decision) in the early phase of the COVID-19 pandemic. Only in 19% of the patients, all key elements of SDM regarding code status were described.

BACKGROUND: Elderly patients undergoing vascular surgery are at a risk of developing postoperative delirium, which is associated with high mortality. Delirium prevention is difficult and is investigated in surgical patients from various specialisms, but little is known about delirium prevention in vascular surgery. For this reason we performed a systematic review on strategies for delirium prevention in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. METHODS: This systematic review included studies describing strategies for preventing delirium in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. The search was conducted using the keywords 'vascular surgery,' 'prevention,' and 'delirium' and was last run on October 21, 2021 in the electronic databases PubMed, MEDLINE, Embase, Web of Science, the Cochrane library, and Emcare. Risk of bias was assessed using the Cochrane risk of bias tool for randomized controlled trials and the ROBINS-1 tool for observational studies. RESULTS: Four studies including 565 patients were included in the systematic review. A significant decrease in the incidence of delirium was reported by a study investigating the effect of comprehensive geriatric assessments within patients undergoing surgery for an aneurysm of the abdominal aorta or lower limb bypass surgery (24% in the control group vs. 11% in the intervention group, P = 0.018) and in the total group of a study evaluating the effect of outpatient clinic multimodal prehabilitation for patients with an aneurysm of the abdominal aorta (11.7% in the control group vs. 8.2% in the intervention group, P = 0.043, Odds Ratio = 0.56). A nonsignificant decrease in delirium incidence was described for patients receiving a multidisciplinary quality improvement at the vascular surgical ward (21.4% in the control group vs. 14.6% in the intervention group, P = 0.17). The study concerning the impact of the type of anesthesia on delirium in 11 older vascular surgical patients, of which 3 developed delirium, did not differentiate between the different types of anesthesia the patients received. CONCLUSIONS: Despite the high and continuous increasing incidence of delirium in the growing elderly vascular population, little is known about effective preventive strategies. An approach to address multiple risk factors simultaneously seems to be promising in delirium prevention, whether through multimodal prehabilitation or comprehensive geriatric assessments. Several strategies including prehabilitation programs have been proven to be successful in other types of surgery and more research is required to evaluate effective preventive strategies and prehabilitation programs in vascular surgical patients. ispartof: ANNALS OF VASCULAR SURGERY vol:85 pages:433-443 ispartof: location:Netherlands status: published

Anne L Meulenbroek,1 Miriam C Faes,2 Stefanie R van Mil,1 MG Buimer,1 Hans GW de Groot,1 Eelco J Veen,1 Gwan H Ho,1 Leandra JM Boonman-de Winter,3,4 Jolanda de Vries,5,6 Rebecca van Gorkom,1 Fleur Toonders,1 Rene van Alphen,7 Karolien van Overveld,8 Nathalie Verbogt,1 Ewout W Steyerberg,9 Lijckle van der Laan1,10 1Department of Surgery, Amphia Hospital, Breda, the Netherlands; 2Department of Geriatrics, Amphia Hospital, Breda, the Netherlands; 3Department of Scientific Research, Amphia Hospital, Breda, the Netherlands; 4Admiraal de Ruyter Ziekenhuis, Goes, the Netherlands; 5Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands; 6Board, Admiraal de Ruyter Hospital, Goes, the Netherlands; 7Department of Physical Therapy, Amphia Hospital, Breda, the Netherlands; 8Department of Dieticians, Amphia Hospital, Breda, the Netherlands; 9Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands; 10Department of Cardiovascular Science, University Hospitals Leuven, Leuven, BelgiumCorrespondence: Anne L Meulenbroek, Department of Surgery, Amphia Hospital, Molengracht 21, Breda, 4818 CK, the Netherlands, Tel +31 76 595 3157, Fax +31 76 595 3818, Email AMeulenbroek1@amphia.nlObjective: Chronic limb threatening ischemia is the final stage of peripheral arterial disease. Current treatment is based on revascularization to preserve the leg. In the older, hospitalized chronic limb threatening ischemia patient, delirium is a frequent and severe complication after revascularization. Delirium leads to an increased length of hospital stay, a higher mortality rate and a decrease in quality of life. Currently, no specific guidelines to prevent delirium in chronic limb threatening ischemia patients exist. We aim to evaluate the effect of a multicomponent, multidisciplinary prehabilitation program on the incidence of delirium in chronic limb threatening ischemia patients ≥ 65 years.Design: A prospective observational cohort study to investigate the effects of the program on the incidence of delirium will be performed in a large teaching hospital in the Netherlands. This manuscript describes the design of the study and the content of this specific prehabilitation program.Methods: Chronic limb threatening ischemia patients ≥ 65 years that require revascularization will participate in the program. This program focuses on optimizing the patient’s overall health and includes delirium risk assessment, nutritional optimization, home-based physical therapy, iron infusion in case of anaemia and a comprehensive geriatric assessment in case of frailty. The primary outcome is the incidence of delirium. Secondary outcomes include quality of life, amputation-free survival, length of hospital stay and mortality. Exclusion criteria are the requirement of acute treatment or patients who are mentally incompetent to understand the procedures of the study or to complete questionnaires. A historical cohort from the same hospital is used as a control group.Discussion: This study will clarify the effect of a prehabilitation program on delirium incidence in chronic limb threatening ischemia patients. New insights will be obtained on optimizing a patient’s preoperative mental and physical condition to prevent postoperative complications, including delirium.Trial: This protocol is registered at the Netherlands National Trial Register (NTR) number: NL9380.Keywords: chronic limb threatening ischemia, vascular surgical procedures, delirium, delirium/prevention and control, prehabilitation

ObjectiveTo provide insight into professionals’ perceptions of and experiences with shared decision-making (SDM) in the treatment of symptomatic patients with severe aortic stenosis (AS).MethodsA semistructured interview study was performed in the heart centres of academic and large teaching hospitals in the Netherlands between June and December 2020. Cardiothoracic surgeons, interventional cardiologists, nurse practitioners and physician assistants (n=21) involved in the decision-making process for treatment of severe AS were interviewed. An inductive thematic analysis was used to identify, analyse and report patterns in the data.ResultsFour primary themes were generated: (1) the concept of SDM, (2) knowledge, (3) communication and interaction, and (4) implementation of SDM. Not all respondents considered patient participation as an element of SDM. They experienced a discrepancy between patients’ wishes and treatment options. Respondents explained that not knowing patient preferences for health improvement hinders SDM and complicating patient characteristics for patient participation were perceived. A shared responsibility for improving SDM was suggested for patients and all professionals involved in the decision-making process for severe AS.ConclusionsProfessionals struggle to make highly complex treatment decisions part of SDM and to embed patients’ expectations of treatment and patients’ preferences. Additionally, organisational constraints complicate the SDM process. To ensure sustainable high-quality care, professionals should increase their awareness of patient participation in SDM, and collaboration in the pathway for decision-making in severe AS is required to support the documentation and availability of information according to the principles of SDM.

Double impact: can our health care system deal with a terrorist attack during the COVID pandemic? Health care organizations have been challenged by the COVID-19 pandemic since the first half of 2020. Both hospitals (especially emergency and intensive care departments) and ambulance services were overwhelmed by surging patient numbers during the 2 pandemic waves in 2020. In this study, the data of the 2016 multisite terrorist bombing attacks in Zaventem (Brussels International Airport) and Maalbeek (subway) are reviewed. It is simulated what the impact of similar attacks would be on an already challenged health care system and which COVID-19-specific measures would be favourable for the outcome. The limited access of ICU beds, operating rooms and surge capacity, as well as the number of COVID-positive victims are cardinal features challenging the medical response to mass casualty incidents of this magnitude. During the COVID-19 pandemic, disaster management is affected by the limited availability of intensive care beds and operation rooms, and the faltering reverse triage negatively influencing the response capacity. On the other hand, the impact of the COVID pandemic can also be favourable. Special concerns on a COVID-19-safe response are discussed. It must be avoided that the medical response and gathering of stranded passengers would become a superspreading event. Multisite terrorist attacks during a pandemic are possibly catastrophic for a health care system which is already beyond its limit in terms of surge capacity. COVID-19-specific recommendations for disaster management in case of terrorist attacks are provided.

Background Considering the current overweight and obesity epidemic and its associated increase in non-communicable diseases and healthcare costs, the current study aimed to project the trends in prevalence of overweight and obesity in Belgium using a Bayesian age-period-cohort (APC) model to support policy planning. Methods Height and weight of 58,369 adults aged 18+ years, collected in six consecutive cross-sectional health interview surveys between 1997 and 2018, were evaluated. Criteria used for overweight and obesity were defined as body mass index (BMI) ≥ 25, and BMI ≥ 30. A Bayesian APC model was applied to evaluate past trends and associated socio-demographic risk factors, and to forecast trends to 2019-2029. All analyses were performed based on integrated nested Laplace approximation (INLA) and took the complex survey design into account. Results The prevalence of overweight and obesity has increased between 1997 and 2018. If current trends continue, it is likely to that a further increase in the prevalence of overweight and obesity in the population will be seen by 2029 with a probability of growth of 51.2% and 73.3%, respectively. Forecasts indicated a potential prevalence of 50.1% [16.2%; 84.4%] in 2029 for overweight, and 21.4% [9.0%; 43.4%] for obesity. Among survey participants, middle-aged men with no higher education and a middle income showed the highest risk of overweight and obesity. Conclusions We projected an alarming increase in the prevalence of overweight and obesity. A decrease in cases seems very unlikely. There is an urgent need to target younger age groups for prevention and implementation of public educational programs to limit the increasing trend in overweight and obesity. Key messages • The occurence of obesity is likely to increase in the following 10 years. • Projection of trends can serve as a useful tool for policy planning on the mid- and longer term.

Objectives: This study aimed to demonstrate the impact of elective major abdominal surgery and subsequent postoperative delirium on quality of life (QOL; primary outcome), cognitive functioning and depressive symptoms (secondary outcomes) in older surgical patients.Method: A single-centre, longitudinal prospective cohort study was conducted between November 2015 and June 2018, including patients ≥70 years old who underwent surgery for colorectal cancer or an abdominal aortic aneurysm. They were followed-up at discharge and at 6 and 12 months postoperatively until June 2019. QOL was assessed with the World Health Organization Quality of Life-BREF questionnaire (WHOQOL-BREF). Cognitive functioning was measured with the Mini-Mental State Examination and depressive symptoms with the CES-D 16.Results: In all patients (n = 265), physical and psychological health were significantly lower at discharge compared to baseline (p Conclusion: Physical and psychological QOL were decreased in the early postoperative period. While physical health was restored after 6 and 12 months, psychological health remained decreased. After 12 months, postoperative delirium resulted in worse psychological, social and environmental QOL and more depressive symptoms. Decreased cognitive functioning may be a risk factor for delirium.

Aim To provide insight into the basic characteristics of decision making in the treatment of symptomatic severe aortic stenosis (SSAS) in Dutch heart centres with specific emphasis on the evaluation of frailty, cognition, nutritional status and physical functioning/functionality in (instrumental) activities of daily living [(I)ADL]. Methods A questionnaire was used that is based on the European and American guidelines for SSAS treatment. The survey was administered to physicians and non-physicians in Dutch heart centres involved in the decision-making pathway for SSAS treatment. Results All 16 Dutch heart centres participated. Before a patient case is discussed by the heart team, heart centres rarely request data from the referring hospital regarding patients’ functionality (n = 5), frailty scores (n = 0) and geriatric consultation (n = 1) as a standard procedure. Most heart centres ‘often to always’ do their own screening for frailty (n = 10), cognition/mood (n = 9), nutritional status (n = 10) and physical functioning/functionality in (I)ADL (n = 10). During heart team meetings data are ‘sometimes to regularly’ available regarding frailty (n = 5), cognition/mood (n = 11), nutritional status (n = 8) and physical functioning/functionality in (I)ADL (n = 10). After assessment in the outpatient clinic patient cases are re-discussed ‘sometimes to regularly’ in heart team meetings (n = 10). Conclusions Dutch heart centres make an effort to evaluate frailty, cognition, nutritional status and physical functioning/functionality in (I)ADL for decision making regarding SSAS treatment. However, these patient data are not routinely requested from the referring hospital and are not always available for heart team meetings. Incorporation of these important data in a structured manner early in the decision-making process may provide additional useful information for decision making in the heart team meeting.

Phenomenological models are popular for describing the epidemic curve. We present how they can be used at different phases in the epidemic, by modelling the daily number of new hospitalisations (or cases). As real-time prediction of the hospital capacity is important, a joint model of the new hospitalisations, number of patients in hospital and in intensive care unit (ICU) is proposed. This model allows estimation of the length of stay in hospital and ICU, even if no (or limited) individual level information on length of stay is available. Estimation is done in a Bayesian framework. In this framework, real-time alarms, defined as the probability of exceeding hospital capacity, can be easily derived. The methods are illustrated using data from the COVID-19 pandemic in March–June 2020 in Belgium, but are widely applicable.

Uptake and results of Covid-19 vaccination during a pandemic in nursing home residents and staff This study involves the participation of residents and staff of 2 Flemish nursing homes in the Covid-19 vaccination program, as well as the subsequent presence and titres of Covid-19 antibodies. With 1 exception, all 259 residents and 94% of the eligible staff members (n = 237) were vaccinated, 16 young female staff members were vaccinated with some delay because of pregnancy and fertility related fears. Post-vaccination SARS-CoV-2 antibody testing was performed in 214 (83%) residents and 201 (85%) staff members. Of these, respectively 98% and 100% had SARS-CoV-2 antibodies. A clear negative association was found between antibody titres and age. Within these nursing homes (and a number of surrounding nursing homes) the vaccination campaign was successful as well as effective.

Background: During the COVID-19 pandemic, the scarcity of resources has necessitated triage of critical care for patients with the disease. In patients aged 65 years and older, triage decisions are regularly based on degree of frailty measured by the Clinical Frailty Scale (CFS). However, the CFS could also be useful in patients younger than 65 years. We aimed to examine the association between CFS score and hospital mortality and between CFS score and admission to intensive care in adult patients of all ages with COVID-19 across Europe. Methods: This analysis was part of the COVID Medication (COMET) study, an international, multicentre, retrospective observational cohort study in 63 hospitals in 11 countries in Europe. Eligible patients were aged 18 years and older, had been admitted to hospital, and either tested positive by PCR for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or were judged to have a high clinical likelihood of having SARS-CoV-2 infection by the local COVID-19 expert team. CFS was used to assess level of frailty: fit (CFS 1–3), mildly frail (CFS 4–5), or frail (CFS 6–9). The primary outcome was hospital mortality. The secondary outcome was admission to intensive care. Data were analysed using a multivariable binary logistic regression model adjusted for covariates (age, sex, number of drugs prescribed, and type of drug class as a proxy for comorbidities). Findings: Between March 30 and July 15, 2020, 2434 patients (median age 68 years [IQR 55–77]; 1480 [61%] men, 954 [30%] women) had CFS scores available and were included in the analyses. In the total sample and in patients aged 65 years and older, frail patients and mildly frail patients had a significantly higher risk of hospital mortality than fit patients (total sample: CFS 6–9 vs CFS 1–3 odds ratio [OR] 2·71 [95% CI 2·04–3·60], p4–5 vs CFS 1–3 OR 1·54 [1·16–2·06], p=0·0030; age ≥65 years: CFS 6–9 vs CFS 1–3 OR 2·90 [2·12–3·97], p4–5 vs CFS 1–3 OR 1·64 [1·20–2·25], p=0·0020). In patients younger than 65 years, an increased hospital mortality risk was only observed in frail patients (CFS 6–9 vs CFS 1–3 OR 2·22 [1·08–4·57], p=0·030; CFS 4–5 vs CFS 1–3 OR 1·08 [0·48–2·39], p=0·86). Frail patients had a higher incidence of admission to intensive care than fit patients (CFS 6–9 vs CFS 1–3 OR 1·54 [1·21–1·97], p=0·0010), whereas mildly frail patients had a lower incidence than fit patients (CFS 4–5 vs CFS 1–3 OR 0·71 [0·55–0·92], p=0·0090). Among patients younger than 65 years, frail patients had an increased incidence of admission to intensive care (CFS 6–9 vs CFS 1–3 OR 2·96 [1·98–4·43], p4–5 vs CFS 1–3 OR 0·93 [0·63–1·38], p=0·72). Among patients aged 65 years and older, frail patients had no significant difference in the incidence of admission to intensive care compared with fit patients (CFS 6–9 vs CFS 1–3 OR 1·27 [0·92–1·75], p=0·14), whereas mildly frail patients had a lower incidence than fit patients (CFS 4–5 vs CFS 1–3 OR 0·66 [0·47–0·93], p=0·018). Interpretation: The results of this study suggest that CFS score is a suitable risk marker for hospital mortality in adult patients with COVID-19. However, treatment decisions based on the CFS in patients younger than 65 years should be made with caution. Funding: LOEY Foundation.

Background Prehabilitation programs have recently been suggested as potentially able to lower the incidence of delirium in elderly patients undergoing major abdominal surgery. For these prehabilitation programs to become successful, it is essential to identify those patients who are most likely to develop a delirium. Material and methods A single-centre cohort study was conducted. Inclusion criteria were: age ≥70 years and scheduled for abdominal surgery for colorectal cancer or an abdominal aortic aneurysm between January 2013 and June 2018. Baseline patient, surgical, anaesthesiologic and haematological characteristics were collected. A risk factor analysis was conducted, with postoperative delirium as primary outcome, by performing a multivariable logistic regression analysis. Results In this study, 627 patients were included, of whom 64 (10%) developed a delirium. Variables that differed significantly between delirious and non-delirious patients were age, burden of comorbidity, renal impairment, hypertension, cognitive impairment, history of delirium, physical and nutritional impairment, open surgery, preoperative anaemia and erythrocyte transfusion. After multivariable logistic regression analysis, risk factors for postoperative delirium after major abdominal surgery were renal impairment (OR 2.2; 95%CI 1.2–4.3), cognitive impairment (OR 4.1; 95%CI 1.8–9.2), an ASA score ≥ 3 (OR 2.0; 95% CI 1.0–3.9), being an active smoker (OR 2.7; 95%CI 1.3–5.8), ICU admission (OR 7.1; 95%CI 3.5–14.3), erythrocyte transfusion (OR 2.4; 95%CI 1.2–4.9) and a diagnosis of colorectal cancer (CRC); (OR 4.0; 95% CI 1.7–9.6). Prehabilitation had a protective effect (OR 0.5; 95% CI 0.3–0.9). Conclusion Postoperative delirium is a frequent complication after major abdominal surgery in the elderly, especially in octogenarians and after open procedures. Renal impairment, cognitive impairment, being an active smoker, ICU admission, erythrocyte transfusion and a diagnosis of CRC are important risk factors for the development of delirium. Prehabilitation lowers the risk of developing a delirium.

Introduction: Coronary arterial stenosis may impair myocardial perfusion with myocardial ischemia and associated morbidity and mortality as result. The myocardial fractional flow reserve (FFR) is clinically used as a stenosis-specific index. Aim: This study aims to identify the relation between the FFR and the degree of coronary arterial stenosis using a simple mathematical model of the coronary circulation. Methods: A mathematical model of the coronary circulation, including an arterial stenosis of variable degree, was developed. The relation between the FFR and the degree of stenosis (defined as the fractional cross sectional area narrowing) was investigated, including the influence of the aortic and venous pressures and the capillary resistance. An additional study concerning 22 patients with coronary artery disease permits comparison of clinical data and in silico findings. Results: The FFR shows an S-shaped relationship with the stenosis index. We found a marked influence of venous and aortic pressure and capillary resistance. The FFR is accompanied by a clinically relevant co-metric (FFRC), defined by the Pythagorean sum of the two pressures in the definition formula for FFR. In the patient group the FFRC is strongly related to the post-stenotic pressure (R = 0.91). The FFRC requires establishment of a validated cut-off point using future trials. Conclusion: The S-shaped dependence of FFR on the severity of the stenosis makes the FFR a measure of the ordinal scale. The marked influences of the aortic and venous pressures and the capillary resistance on the FFR will be interpreted as significant variations in intra- and inter-individual clinical findings. These fluctuations are partly connected to the neglect of considering the FFRC. At otherwise identical conditions the FFR as measured at baseline differs from the value obtained during hyperemic conditions. This expected observation requires further investigation, as the current hyperemia based evaluation fails to take advantage of available baseline data.

This review provides an overview of the status of shared decision making (SDM) in older patients regarding treatment of symptomatic severe aortic stenosis (SSAS). The databases Embase, Medline Ovid, Cinahl and Cochrane Dare were searched for relevant studies from January 2002 to May 2018 regarding perspectives of professionals, patients and caregivers; aspects of decision making; type of decision making; application of the six domains of SDM; barriers to and facilitators of SDM. The systematic search yielded 1842 articles, 15 studies were included. Experiences of professionals and informal caregivers with SDM were scarcely found. Patient refusal was a frequently reported result of decision making, but often no insight was given into the decision process. Most studies investigated the ‘decision’ and ‘option’ domains of SDM, yet no study took all six domains into account. Problem analysis, personalised treatment aims, use of decision aids and integrating patient goals in decisions lacked in all studies. Barriers to and facilitators of SDM were ‘individualised formal and informal information support’ and ‘patients’ opportunity to use their own knowledge about their health condition and preferences for SDM’. In conclusion, SDM is not yet common practice in the decision making process of older patients with SSAS. Moreover, the six domains of SDM are not often applied in this process. More knowledge is needed about the implementation of SDM in the context of SSAS treatment and how to involve patients, professionals and informal caregivers.

Introduction La microlithiase alveolaire pulmonaire (MAP) est une pathologie infiltrante pulmonaire, rare, caracterisee par la presence de cristaux d’hydroxyapatite dans l’espace alveolaire. Decrite initialement par Malpighi en 1686, moins de 1500 cas ont ete rapportes dans la litterature. La MAP est d’origine genetique, autosomique recessive, resultant d’une mutation du gene SLC34A2 codant pour un cotransporteur sodium-phosphate. Le seul traitement disponible a ce jour est la transplantation pulmonaire. Cas clinique Nous rapportons le cas d’un homme de 34 ans, hospitalise pour dyspnee d’apparition progressive en quelques mois. L’angioscanner thoracique realise a la recherche d’une embolie pulmonaire a revele une micronodulation diffuse spontanement hyperdense, faisant evoquer le diagnostic de MAP. La scintigraphie osseuse realisee selon des images planaires du corps entier a deux heures de l’injection du 99mTc-HMDP a mis en evidence une hyperfixation diffuse du parenchyme pulmonaire, superieure a celle du squelette. Cet aspect scintigraphique est tres evocateur d’une MAP. Le resultat de l’analyse genetique obtenu deux mois plus tard confirma le diagnostic en retrouvant la mutation du gene SLC34A2. Le patient est actuellement entre dans un projet de transplantation pulmonaire. Discussion Par son aspect scintigraphique caracteristique et son pronostic defavorable en l’absence de traitement, la MAP est une pathologie a reconnaitre en scintigraphique osseuse. Sa decouverte survient sur une imagerie systematique dans la majorite des cas. Un pattern scintigraphique similaire est rapporte en TEP au 18F-FNa, non retrouve en TEP au 18F-FDG. Une hyperfixation des metacarpes et phalanges a ete decrite en scintigraphie osseuse correspondant a un hippocratisme digital, retrouve chez 7 % des sujets atteints de MAP. Bien que l’hyperfixation isolee du parenchyme pulmonaire apparaisse typique de la MAP, d’autres etiologies peuvent etre a l’origine d’une fixation pulmonaire en scintigraphie osseuse, principalement les microcalcifications metastatiques en lien avec une hypercalcemie, l’amylose ou l’insuffisance renale elle-meme. Conclusion La microlithiase alveolaire pulmonaire est une pathologie extra-squelettique dont l’aspect en scintigraphie osseuse est caracteristique.

Objective This study aims to compare the major anatomical aspects among anterolateral thigh, parascapular and lateral arm flaps. Methods Sixty flaps were dissected in 20 human cadavers, comparing their vascular pedicle length, flap thickness and arterial/venous pedicle diameters. Results The vascular pedicle length (from the origin of the vascular pedicle to its entry into the skin flap) of anterolateral thigh flap (13.43 ± 3.92 cm, lateral circumflex femoral artery) was longer than parascapular (9.07 ± 1.20 cm, circumflex scapular artery) and lateral arm flap (8.90 ± 1.65 cm, posterior collateral radial artery) (P

Spatio-temporal analysis of small area health data often involves choosing a fixed set of predictors prior to the final model fit. In this paper, we propose a spatio-temporal approach of Bayesian model selection to implement model selection for certain areas of the study region as well as certain years in the study time line. Here, we examine the usefulness of this approach by way of a large-scale simulation study accompanied by a case study. Our results suggest that a special case of the model selection methods, a mixture model allowing a weight parameter to indicate if the appropriate linear predictor is spatial, spatio-temporal, or a mixture of the two, offers the best option to fitting these spatio-temporal models. In addition, the case study illustrates the effectiveness of this mixture model within the model selection setting by easily accommodating lifestyle, socio-economic, and physical environmental variables to select a predominantly spatio-temporal linear predictor.

Impedance cardiography (ICG) is a method to evaluate cardiac-stroke volume and cardiac-output by measuring the cardiac-synchronous changes in the dynamic trans-thoracic electrical impedance (ΔZ). Clinical evaluations on the accuracy of ICG showed varying results. Consequently, the classic assumption in ICG-the aorta as a main source of ΔZ-is questioned and subsequently investigated in simulation studies using mathematical models of the electrical resistivity of the human body. The aim is to review the consensus in mathematical modelling studies that investigate the origin of the ΔZ as measured in ICG. In a systematic literature search, studies were identified and surveyed with reference to characteristics, such as included organs and their resistivity and geometries, electrode positions and calculation of ΔZ, to review the consensus between mathematical modelling studies that investigate the origin of the ΔZ as measured in ICG. Thirteen papers showed considerable variation in the model's characteristics with varying or contradicting outcomes for the ΔZ 's origin. For instance, 11 studies excluded perfused muscle tissue, implying implicitly their insignificance, while 3 other studies included muscle tissue and indicated it as the most important origin of ΔZ. In conclusion, the reviewed papers show a lack of consensus with respect to both the modelled characteristics as well as the model outcomes and, as a result, these studies failed to settle the controversy on ΔZ 's origin. Recommendations have been added to improve future mathematical model studies.

Item does not contain fulltext Complex interventions are difficult to develop, document, evaluate, and reproduce. Process evaluations aid the interpretation of outcome results by documenting and evaluating each process step in detail. Despite its importance, process evaluations are not embedded in all evaluations of complex interventions. Based on literature, we structured the process evaluation for trials on complex interventions into 3 main components: (1) the success rate of recruitment and quality of the study population, (2) the quality of execution of the complex intervention, and (3) the process of acquisition of the evaluation data. To clarify these process evaluation components and measures, we exemplified them with the preplanned process evaluation of a complex falls-prevention program for community-dwelling frail older fallers and their informal caregivers. The 3 process evaluation components are operationalized, results are presented, and implications discussed. This process evaluation identified several limitations of the intervention and effect study, and resulted in multiple recommendations for improvement of both the intervention as well as the trial. Thus, a good-quality process evaluation gives a detailed description of the most important components of a complex intervention, resulting in an in-depth insight in the actually performed intervention and effect analysis. This allows us to draw the appropriate conclusions on positive or negative trial results, and results in recommendations for implementation, or adjustment of the intervention or effect evaluation, respectively. 6 p.

Geriatrics focuses on a variety of multiorgan problems in a heterogeneous older population. Therefore, most geriatric healthcare interventions are complex interventions. The UK Medical Research Council (MRC) has developed a framework to systematically design, evaluate, and implement complex interventions. This article provides an overview of this framework and illustrates its use in geriatrics by showing how it was used to develop and evaluate a fall prevention intervention. The consecutive phases of the framework are described: Phase I: Development. This phase began with a literature review, which provided the existing evidence and the theoretical understanding of the process of change. This understanding was further developed through focus groups with experts and interviews with patients and caregivers. The intervention was modeled using qualitative testing of the preliminary intervention through focus groups and through the completion of Delphi surveys by independent specialists. Phase II: Feasibility and piloting. In this phase, a pilot study was conducted in a group of patients and caregivers. The feasibility of the intervention and evaluation was also discussed in focus groups of participants and instructors. Phase III: Evaluation. The information from phases I and II shaped the design of a randomized controlled trial to test the effectiveness of the intervention. Phase IV: Dissemination. The purpose of the final phase is to examine the implementation of the intervention into practice. The MRC framework provides an innovative and useful methodology for the development and evaluation of complex geriatric interventions that deserves greater dissemination and implementation.

Contains fulltext : 89142reelick.pdf (Publisher’s version ) (Closed access) OBJECTIVES: In randomized controlled trials with many potential prognostic factors, serious imbalance among treatment groups regarding these factors can occur. Minimization methods can improve balance but increase the possibility of selection bias. We described and evaluated the performance of a new method of treatment allocation, called studywise minimization, that can avoid imbalance by chance and reduce selection bias. STUDY DESIGN AND SETTING: The studywise minimization algorithm consists of three steps: (1) calculate the imbalance for all possible allocations, (2) list all allocations with minimum imbalance, and (3) randomly select one of the allocations with minimum imbalance. We carried out a simulation study to compare the performance of studywise minimization with three other allocation methods: randomization, biased-coin minimization, and deterministic minimization. Performance was measured, calculating maximal and average imbalance as a percentage of the group size. RESULTS: Independent of trial size and number of prognostic factors, the risk of serious imbalance was the highest in randomization and absent in studywise minimization. The largest differences among the allocation methods regarding the risk of imbalance were found in small trials. CONCLUSION: Studywise minimization is particularly useful in small trials, where it eliminates the risk of serious imbalances without generating the occurrence of selection bias. 01 oktober 2010

Contains fulltext : 89562reelick.pdf (Publisher’s version ) (Closed access) OBJECTIVES: The primary aim of this study was to explore the impact of falling for frail community-dwelling older persons with and without cognitive impairments who have experienced a recent fall and their primary family caregivers. The secondary aim was to define components for a future fall prevention programme. METHODS: Grounded theory interview study, with 10 patients (three cognitively unimpaired, four with mild cognitive impairment and three with dementia) and 10 caregivers. RESULTS: All patients described a fear of falling and social withdrawal. Caregivers reported a fear of their care recipient (CR) falling. Most patients were unable to name a cause for the falls. Patients rejected the ideas that falling is preventable and that the fear of falling can be reduced. Some caregivers rated the consequences of their CRs' cognitive problems as more burdensome than their falls and believed that a prevention programme would not be useful because of the CRs' cognitive impairment, physical problems, age and personalities. CONCLUSION: Falling has major physical and emotional consequences for patients and caregivers. A fall prevention programme should focus on reducing the consequences of falling and on promoting self-efficacy and activity. The causes of falls should be discussed. The programme should include dyads of patients and caregivers because caregivers are highly involved and also suffer from anxiety. Before beginning such a programme, providers should transform negative expectations about the programme into positive ones. Finally, caregivers must learn how to deal with the consequences of their CRs' falling as well as their cognitive impairment. 01 september 2010

Contains fulltext : 70990.pdf (Publisher’s version ) (Closed access) Research on geriatric syndromes has helped to clarify risk factors and established effective intervention strategies, yet the results based on this evidence have mostly failed to translate into clinical practice. The translation of geriatric syndrome research into practice faces unique challenges, which may heighten the barriers to evidence-based implementation. The British Medical Research Council framework (MRC) for development and evaluation of complex interventions, turns out to be very valuable in developing and evaluating interventions in the complex clinical reality of geriatrics. This paper illustrates the different phases of this framework on the basis of examples from geriatric research projects in The Netherlands. The discussed barriers in complex interventions can be mapped using the different phases in the MRC-framework and thus become feasible challenges for good quality research.

Epicondylitis lateralis, ofwel tenniselleboog, werd in 1873 voor het eerst beschreven als ‘writers cramp’ (Runge, 1873). Deze aandoening wordt gekenmerkt door pijn rondom de laterale epicondyl van de humerus die toeneemt door dorsiflexie van de pols en door palpatie van het gebied rondom de epicondyl. Meestal is de dominante arm aangedaan, terwijl er in voorkomen geen noemenswaardig verschil per geslacht is. Met een incidentie van 4-7 patienten per 1000 per jaar en een prevalentie van 1 tot 3% is epicondylitis lateralis een veelvoorkomende klacht (Smidt e.a., 2002). De incidentie is het hoogst in de leeftijdscategorie van 40-50 jaar. Meer dan de helft van de patienten met epicondylitis gaat niet naar de huisarts. Van de patienten die de huisarts consulteren, wordt 20-40% doorgestuurd naar de fysiotherapeut en wordt 3-6% doorverwezen naar de tweede lijn (meestal orthopedisch chirurg) (NHG Standaard (NHG)).

Contains fulltext : 51159.pdf (Publisher’s version ) (Closed access) STUDY DESIGN: Semiexperimental study. OBJECTIVE: To investigate the effect of an external wrist extension force on extensor muscle activity during hand gripping in patients with lateral epicondylalgia. BACKGROUND: Lateral epicondylalgia or "tennis elbow" is a common, often disabling ailment affecting millions of people. An optimal treatment strategy remains to be identified. The use of an external wrist extension force may reduce the extensor muscle activity during gripping in these patients. METHODS: Muscle activity of the extensor carpi radialis brevis (ECRB), extensor digitorum communis (EDC), and extensor carpi radialis longus (ECRL) was measured using surface EMG. Subjects gripped at an intensity of 10%, 20%, and 30% of the maximum voluntary contraction (MVC) force with and without the dynamic extensor brace and with and without an applied external wrist extension force of 1%, 2%, and 3% of MVC. RESULTS: At all levels of MVC gripping, the EMG signal of the ECRB and EDC were significantly lower for gripping with than without brace. An extension force of 3% of the MVC force significantly reduced the EMG signal of all muscles in almost all measurement conditions. CONCLUSIONS: The results of this study indicate that the dynamic extensor brace as well as the external extension force significantly reduced the EMG signal of the wrist extensor muscles during gripping in patients with lateral epicondylalgia. Based on these results, the dynamic extensor brace could be a promising new intervention for lateral epicondylalgia.

Lateral epicondylitis (tennis elbow) is a common, often disabling ailment. Based on the failure of current therapies, a new dynamic extensor brace has been developed. In this study, the effects of application of this brace for 3 months on the most important and disabling symptoms of patients with lateral epicondylitis were assessed. After prestratification for the duration of complaints (ie, or = 3 months), 63 patients initially were assigned randomly to 12 weeks of brace treatment (Group 1; n = 30) or no brace treatment (Group 2; n = 33). Outcome measures included pain (VAS), pain-free grip strength, maximum grip strength, and functionality of the arm. All outcomes were assessed at 6, 12, 18, and 24 weeks. Brace treatment resulted in significant pain reduction, improved functionality of the arm, and improvement in pain-free grip strength. The beneficial effects of the dynamic extensor brace observed after 12 weeks were significantly different from the treatment group that received no brace. The beneficial effects were sustained for another 12 weeks. No correlation between duration of symptoms and treatment effects of the brace was revealed. The dynamic extensor brace is an effective therapeutic tool for treating lateral epicondylitis. Level of Evidence: Therapeutic study. Level I (randomized controlled trial with statistically significant difference). See the Guidelines for Authors for a complete description of levels of evidence.

This study aims to compare the major anatomical aspects among anterolateral thigh, parascapular and lateral arm flaps.Sixty flaps were dissected in 20 human cadavers, comparing their vascular pedicle length, flap thickness and arterial/venous pedicle diameters.The vascular pedicle length (from the origin of the vascular pedicle to its entry into the skin flap) of anterolateral thigh flap (13.43 ± 3.92 cm, lateral circumflex femoral artery) was longer than parascapular (9.07 ± 1.20 cm, circumflex scapular artery) and lateral arm flap (8.90 ± 1.65 cm, posterior collateral radial artery) (P 0.001). The thickness of lateral arm flap (6.32 ± 2.33 mm) was lesser than parascapular (8.59 ± 2.93 mm) and anterolateral thigh flap (9.30 ± 3.54 mm) (P 0.001). The arterial/venous pedicle diameters of lateral arm flap (2.37 ± 0.69 mm / 2.61 ± 0.74 mm) were lesser than parascapular (3.46 ± 0.80 mm / 4.07 ± 0.87 mm) and anterolateral thigh flap (3.26 ± 0.74 mm / 3.87 ± 0.70 mm) (P 0.001).The vascular pedicle length of anterolateral thigh flap was the longest and that lateral arm flap presented a pedicle with the smallest arterial and venous diameters, in addition to being the thinnest flap.

The electric resistivity of various human tissues has been reported in many studies, but on comparison large differences appear between these studies. The aim of this study was to investigate systematically the resistivities of human tissues as published in review studies (100 Hz-10 MHz). A data set of 103 resistivities for 21 different human tissues was compiled from six review studies. For each kind of tissue the mean and its 95% confidence interval were calculated. Moreover, an analysis of covariance showed that the calculated means were not statistically different for most tissues, namely skeletal (171 omega cm) and cardiac (175 omega cm) muscle, kidney (211 omega cm), liver (342 omega cm), lung (157 omega cm) and spleen (405 omega cm), with bone (> 17,583 omega cm), fat (3,850 omega cm) and, most likely, the stratum corneum of the skin having higher resistivities. The insignificance of differences between various tissue means could imply an equality of their resistivities, or, alternatively, could be the result of the large confidence intervals which obscured real existing differences. In either case, however, the large 95% confidence intervals reflected large uncertainties in our knowledge of resistivities of human tissues. Applications based on these resistivities in bioimpedance methods, EEG and EKG, should be developed and evaluated with these uncertainties in mind.

The reconstruction problem of electrical impedance tomography (EIT) is to estimate the distribution of the conductivity inside an object from measured potential distributions on the circumference caused by injected current patterns. Mathematically, this reconstruction problem is an ill-posed nonlinear inverse problem, with many unknowns. In this paper, the ill-posed nature is demonstrated by analyzing the condition of the sensitivity matrix; the associated inverse problem can only be solved on a very coarse grid. To circumvent the ill-posed nature of the EIT reconstruction problem, we present a new parametric formulation. In this formulation, it is assumed that the object consists of compartments with homogeneous conductivity. The position, orientation, size, and conductivity of these compartments are treated as unknown parameters, which are determined by solving the forward problem (using the boundary element method) and optimizing the parameters (using Powell's or the simplex method) in order to fit the parameters to the EIT data. Simulations show that the parametric method is stable and adequately solves the EIT problem.

An approach to determine intra- and extracellular conduction on the basis of Bode analysis is presented. Estimation of the ratio between intra- and extracellular conduction could be performed by phase measurement only, midrange in the bandwidth of interest. An important feature is that the relation between intra- and extracellular conduction can be continuously monitored by phase measurement and no curve fitting whatsoever is required. Based on a two-frequency measurement determining Re at 4 kHz and phi max at 64 kHz, it proved possible to estimate extracellular volume (ECV) in 23 patients. Reference values on ECV were determined by sodium bromide. The results show a good correlation (r = 0.90) with the reference method. The average error of ECV estimation was -3.6% (SD 8.4).

Design concepts for the implementation of two basic functions for measurement of electrical impedance are presented: current injection and voltage measurement. At relatively high frequencies, the application of an alternating current through the body or a body segment results in electromagnetic stray fields that reduce the amount of current actually injected into the tissue under study. It is shown that electrical isolation and small dimensions of the isolated section are indispensable in order to substantially reduce these stray currents. The paper describes a new wideband current source configuration driven by direct digital sine wave synthesis (DDS) presenting very low stray currents due to a symmetrical layout. Two implementations of the actual current source circuit are presented: (1) a voltage-controlled system and (2) a current conveyor-based circuit. A wideband input amplifier with transformer coupling is described. The current source, amplifier, and (in case of tomography) multiplexer are also situated on an electrically isolated front end. The presented concepts are applied in a new electrical impedance tomograph (EIT) presently under construction in our department.

The study investigates the effects of non-cardiogenic oedema, especially the accumulation of protein in extracellular fluid, on thoracic impedance and proposes a new method of oedema measurement based on an impedance ratio from a dual-frequency measurement. In vitro measurements in a cell containing an albumin-in-saline solution yield a resistance increase when the albumin concentration increases. Subsequently, 13 patients having acute respiratory failure are measured. The single-frequency Z0 measurements and the proposed impedance ratio are compared with extravascular lung water (EVLW) determined by the double indicator dilution method. The single-frequency measurement correlates poorly with EVLW (r = -0.24, p = 0.56). In some patients, a total thoracic impedance increase is found with increasing EVLW. The correlation between the impedance ratio and EVLW is r = -0.79 (p

The purpose of this study was to investigate the influence of pulmonary oedema as measured with the double indicator dilution technique on the accuracy of cardiac output (CO) measurement using thoracic impedance cardiography (TIC) compared with thermodilution in thirteen sepsis patients. Differences in the Kubicek and Sramek-Bernstein equation with respect to pulmonary oedema were explored theoretically and experimentally. From a parallel two cylinder model a hypothesis can be derived that CO determined with the Kubicek equation is oedema independent, whereas CO determined using the Sramek-Bernstein equation is oedema dependent. Experimentally, CO determined using Kubicek's equation correlated better with thermodilution CO (r = 0.75) than CO determined with the Sramek-Bernstein equation (r = 0.25). The effect of oedema on the accuracy of TIC was investigated by comparing the differences in the CO of impedance and thermodilution to the extravascular lung water index. For the Kubicek equation the difference was not influenced by oedema (r = 0.04, p = 0.84), whereas for the Sramek-Bernstein equation the difference was affected by oedema (r = 0.39, p = 0.05). Thus, the effects of pulmonary oedema on the accuracy of TIC measurements can better be understood with the parallel cylinder model. Moreover, the Kubicek equation still holds when pulmonary oedema is present, in contrast to the Sramek-Bernstein equation.

The effect of Na+/H+ exchange inhibition in neutrophil-induced reperfusion injury was investigated using a new amiloride analogue, 5-methyl-N-isobutyl amiloride (MIA).Rat neutrophils were separated using Percoll gradient. Luminol chemiluminescence intensity of isolated neutrophils was depressed by MIA in a dose-dependent manner.The effect of MIA on neutrophil-induced reperfusion injury was evaluated in Langendorff-perfused rat hearts subjected to 30 minutes of normothermic ischemia. Postischemic left ventricular developed pressure recovery was depressed by the reperfusion with neutrophils (60% +/- 7% to 33% +/- 26%) and was reverted by MIA pretreatment (86% +/- 17%, p0.05). MIA also improved percent recovery of coronary flow (51% +/- 2% to 70% +/- 13%), reduced creatine kinase (0.28 +/- 0.1 to 0.085 +/- 0.03 IU.L-1.g-1 dry wt), and lactate dehydrogenase leakage (10.6 +/- 3.8 to 5.16 +/- 1.3 IU.L-1.g-1 dry wt) significantly. The incidence of reperfusion-induced ventricular fibrillation also was reduced by MIA.The inhibition of Na+/H+ exchange shows a protective effect against neutrophil-induced reperfusion injury possibly by inhibiting the activation of neutrophils.

L’hyperparathyroidie primaire (HPP) est majoritairement asymptomatique mais semble modulee par le statut en vitamine D (VD). Objectif Evaluer le statut en VD et son impact sur la presentation de l’HPP chez des sujets vivant en zone tropicale. Patients-methodes Etude retrospective (2008–2014), colligeant les donnees cliniques, biologiques, morphologiques et fonctionnelles de sujets hospitalises pour exploration d’une HPP. Analyse du statut en VD et de la presentation initiale des sujets. Resultats Soixante-deux sujets inclus (62 ± 15 ans, 74 % F dont 56,5 % en menopause). 75,8 % des sujets etaient asymptomatiques. Dosage de la VD dans 74,2 % des cas. 69,6 % des sujets avaient une VD Conclusion La prevalence de la deficience en VD est elevee chez les sujets avec HPP vivant en zone tropicale mais ne modifie pas la presentation clinique de l’HPP. Cependant, la substitution en VD preoperatoire doit etre systematique pour eviter l’impact deletere de la PTH sur l’os.

Item does not contain fulltext OBJECTIVE: In some trials, the intervention is delivered to individuals in groups, for example, groups that exercise together. The group structure of such trials has to be taken into consideration in the analysis and has an impact on the power of the trial. Our aim was to provide optimal methods for the design and analysis of such trials. STUDY DESIGN AND SETTING: We described various treatment allocation methods and presented a new allocation algorithm: optimal batchwise minimization (OBM). We carried out a simulation study to evaluate the performance of unrestricted randomization, stratification, permuted block randomization, deterministic minimization, and OBM. Furthermore, we described appropriate analysis methods and derived a formula to calculate the study size. RESULTS: Stratification, deterministic minimization, and OBM had considerably less risk of imbalance than unrestricted randomization and permuted block randomization. Furthermore, OBM led to unpredictable treatment allocation. The sample size calculation and the analysis of the study must be based on a multilevel model that takes the group structure of the trial into account. CONCLUSION: Trials evaluating interventions that are carried out in subsequent groups require adapted treatment allocation, power calculation, and analysis methods. From the perspective of obtaining overall balance, we conclude that minimization is the method of choice. When the number of prognostic factors is low, stratification is an excellent alternative. OBM leads to better balance within the batches, but it is more complicated. It is probably most worthwhile in trials with many prognostic factors. From the perspective of predictability, a treatment allocation method, such as OBM, that allocates several subjects at the same time, is superior to other methods because it leads to the lowest possible predictability. 01 februari 2012

Aims: To study and compare both mean performance measures as well as intra-individual variability measures of stride length and reaction time in vulnerable recurrent and non-recurrent older fallers. Methods: Stride length during walking and walking while dual-tasking (GAITRite®) and choice reaction time (CANTAB®) were assessed in geriatric outpatients and their informal caregivers (n=60, ≥60 yrs). Logistic regression and Receiver Operating Characteristic (ROC) analysis were used to generate models with mean performance measures and intra-individual variability measures (coefficients of variation; CV=[sd/mean]×100)), as risk factors for recurrent falls. Results: Reaction-time CV was higher in recurrent fallers than in non-recurrent fallers: 21.3% [9.3–47.7] vs 15.8% [8.3–34.9] (p=0.04). Also, stride-length CV was higher in recurrent fallers during performance of the verbal fluency dual-task: 4.5% [1.2–31.4] vs 3.5% [0.9–9.7] (p=0.017). The model with CVs provided an explained variance of 23.7%, and an area under the curve (AUC) of 0.73, which was higher than that of the model including mean performance measures (8.6% and 0.65 respectively). Conclusions: Older recurrent fallers are characterized by increased within-task variability in reaction time and stride length while dualtasking. In addition, variability in performance is a more sensitive measure in discrimination of recurrent falls than mean performance itself, suggesting deterioration in neurocognitive regulation mechanisms as part of the causal pathway for recurrent falls.

Geriatrics focuses on a variety of multiorgan problems in a heterogeneous older population. Therefore, most geriatric healthcare interventions are complex interventions. The UK Medical Research Council (MRC) has developed a framework to systematically design, evaluate, and implement complex interventions. This article provides an overview of this framework and illustrates its use in geriatrics by showing how it was used to develop and evaluate a fall prevention intervention. The consecutive phases of the framework are described: Phase I: Development. This phase began with a literature review, which provided the existing evidence and the theoretical understanding of the process of change. This understanding was further developed through focus groups with experts and interviews with patients and caregivers. The intervention was modeled using qualitative testing of the preliminary intervention through focus groups and through the completion of Delphi surveys by independent specialists. Phase II: Feasibility and piloting. In this phase, a pilot study was conducted in a group of patients and caregivers. The feasibility of the intervention and evaluation was also discussed in focus groups of participants and instructors. Phase III: Evaluation. The information from phases I and II shaped the design of a randomized controlled trial to test the effectiveness of the intervention. Phase IV: Dissemination. The purpose of the final phase is to examine the implementation of the intervention into practice. The MRC framework provides an innovative and useful methodology for the development and evaluation of complex geriatric interventions that deserves greater dissemination and implementation.