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One possible area of intervention to prevent postoperative delirium (PD) is intraoperative blood pressure management. However, the relationship between intraoperative blood pressure and PD is unclear. A secondary analysis of a RCT study examining the PD risk over the range of absolute intraoperative mean arterial blood pressure (MAP) readings and the corresponding relative changes from preoperative baseline level was performed to determine the role of MAP on PD. Nonparametric locally weighted quadratic polynomial smoothing (LOESS) regression explored the pattern of PD risk at postoperative day 2 as a function of mean surgery MAP (msMAP) and percent change of msMAP from baseline in 103 elderly hip fracture patients. Segment-linear logistic regression models were then constructed to determine the odds ratios (OR) of PD over the observed range of these msMAP measures, adjusting for potential confounds. Twenty-three patients (22%) developed PD on day 2. LOESS regression revealed a j-shaped association between absolute levels of msMAP and PD risk. When msMAP was ≥80 mmHg, higher msMAP imparted greater PD risk (OR = 2.28 per 10 mmHg msMAP increase; 95% CI: 1.11-4.70), while higher msMAP was associated with lower PD risk (OR = 0.19 per 10 mmHg increase; CI: 0.05-0.76) if msMAP was <80 mmHg. There was no statistically significant relationship between PD risk and average percent change from baseline in these msMAP measures. In elderly hip fracture patients, both very high and very low levels of msMAP were associated with significantly increased risk of PD.

This trial showed that two types of behavioral interventions, one based on remote, call-center support and the other on in-person support, resulted in significant weight loss among obese patients. These results provide templates for effective weight-loss programs in primary care practices. Obesity is an important and growing public health problem around the world. In the United States, approximately one third of adults are obese. 1 Obesity adversely affects each of the major cardiovascular risk factors — blood pressure, lipid profile, and diabetes. As a consequence, obese persons have an increased risk of death, especially from cardiovascular disease. 2 , 3 The economic burden of the obesity epidemic is enormous; the estimated direct and indirect costs related to obesity exceed $110 billion annually in the United States. 4 An extensive body of evidence from efficacy trials has shown that weight loss is achievable and that modest . . .

Background Frailty has been associated with postoperative delirium (POD). Studies suggest that the Fried phenotype has a stronger association with POD than the Edmonton Frailty Scale (EFS) criteria. Although phenotypic frailty is recognized as a good predictor of delirium, the EFS has higher ratings for feasibility in the surgical setting. Thus, our aim was to determine the association between EFS-assessed vulnerability and POD in an elective surgical population of older adults. A secondary aim was to determine which domains assessed by the EFS were closely associated with POD. Methods After IRB approval was received, electronic medical records of surgical patients at our institution were downloaded from 12/1/2018 to 3/1/2020. Inclusion criteria included age ≥ 65 years, preoperative EFS assessment within 6 months of surgery, elective surgery not scheduled for intensive care unit (ICU) stay but followed by at least 1 day postoperative stay, and at least two in-hospital evaluations with the 4 A’s test (arousal, attention, abbreviated mental test-4, acute change [4AT]) on the surgical ward. Vulnerability was determined by EFS score ≥ 6. Patients were stratified into two groups according to highest postoperative 4AT score: 0–3 (no POD) and ≥ 4 (POD). Odds of POD associated with EFS score ≥ 6 were evaluated by using logistic regression adjusted for potential confounders. Results The dataset included 324 patients. Vulnerability was associated with higher incidence of POD ( p  = 0.0007, Fisher’s exact). EFS ≥6 was consistently associated with POD in all bivariate models. Vulnerability predicted POD in multivariable modeling (OR = 3.5, 95% CI 1.1 to 11.5). Multivariable analysis of EFS domains revealed an overall trend in which higher scores per domain had a higher odds for POD. The strongest association occurred with presence of incontinence (OR = 3.8, 95% CI 1.2 to 11.0). Conclusions EFS criteria for vulnerability predict POD in older, non-ICU patients undergoing elective surgery.

Cross-Sectional and Prospective Study of Lung Function in Adults With Type 2 Diabetes The Atherosclerosis Risk in Communities (ARIC) Study Hsin-Chieh Yeh , PHD 1 2 , Naresh M. Punjabi , MD, PHD 1 2 , Nae-Yuh Wang , PHD 2 , James S. Pankow , PHD 3 , Bruce B. Duncan , MD, PHD 4 , Christopher E. Cox , MD, MPH 5 , Elizabeth Selvin , PHD, MPH 1 and Frederick L. Brancati , MD, MHS 1 2 1 Department of Epidemiology, The Johns Hopkins University, Baltimore, Maryland 2 Department of Medicine, The Johns Hopkins University, Baltimore, Maryland 3 Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota 4 Division of Social Medicine Department, Federal University of Rio Grande do Sul, Porto Alegre, Brazil 5 Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina Address correspondence and reprint requests to Dr. Frederick L. Brancati, Division of General Internal Medicine, The Johns Hopkins University, 2024 E. Monument St., Suite 2-600, Baltimore, MD 21205. E-mail: fbrancat{at}jhmi.edu Abstract OBJECTIVE —The aim of this study was to test the hypothesis that diabetes is independently associated with reduced lung function, both cross-sectionally and longitudinally. RESEARCH DESIGN AND METHODS —We conducted cross-sectional and prospective analyses of diabetes status and lung function decline using baseline and 3-year follow-up data on 1,100 diabetic and 10,162 nondiabetic middle-aged adults from the Atherosclerosis Risk in Communities (ARIC) Study. Forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV 1 ) were measured at baseline and at the 3-year follow-up using standard spirometry. RESULTS —At baseline, adults with diabetes had significantly lower predicted FVC (96 vs. 103%, P < 0.001) and predicted FEV 1 (92 vs. 96%, P < 0.001) than those without diabetes. These differences remained significant after adjustment for demographic characteristics, adiposity, smoking, physical activity index, education, and ARIC field center. Graded, inverse associations were observed between hyperglycemia, diabetes severity (i.e., duration of diabetes and types of antidiabetes medications), and FVC and FEV 1 (all P trend < 0.001). In prospective analyses, FVC declined faster in diabetic adults than in their nondiabetic counterparts (64 vs. 58 ml/year, P = 0.01). Diabetes severity as indicated by intensity of antidiabetic treatment also showed graded relationships with the rate of FVC decline ( P < 0.01). CONCLUSIONS —These data support the notion that the lung is a target organ for diabetic injury. Additional research is required to identify pathophysiologic mechanisms and to determine clinical significance. ARIC, Atherosclerosis Risk in Communities FEV1, forced expiratory volume in 1 s FVC, forced vital capacity Footnotes Published ahead of print at http://care.diabetesjournals.org on 4 December 2007. DOI: 10.2337/dc07-1464. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C Section 1734 solely to indicate this fact. See accompanying editorial, p. 828 . Accepted November 22, 2007. Received July 29, 2007. DIABETES CARE

Background  People with serious mental illness die 10–20 years earlier than the overall population, mainly from cardiovascular disease. Although effective interventions to manage cardiovascular disease risk in this population exist, they have not been widely implemented in community settings. IDEAL Goals is an empirically supported, cardiovascular risk reduction program tailored for people with serious mental illness (i.e., “clients”) and designed to be delivered by clinicians and staff in community mental health settings. In this trial, we use Replicating Effective Programs (REP) as the foundational implementation strategy to test the effects of two additional strategies, Coaching and Facilitation, on improving the number of IDEAL Goals sessions clients receive in community mental health organizations in Maryland and Michigan. Methods  This cluster-randomized hybrid Type 3 effectiveness-implementation trial will use a non-restricted sequential, multiple-assignment randomized trial (SMART) design that randomizes organizations at two points, months 0 and 6, of the 18-month IDEAL Goals intervention. Organizations will receive one of four sequences of implementation strategies: (1) REP only; (2) REP + Coaching; (3) REP + Facilitation; or (4) REP + Coaching + Facilitation. The primary aim is to determine the effect of the most intensive sequence of strategies (REP + Coaching + Facilitation) versus REP only on the number of IDEAL Goals sessions clients receive over 18 months. The secondary aim is to determine the marginal effects of Coaching and Facilitation on the number of IDEAL Goals sessions clients receive over 18 months. Exploratory aims include: (1) assessing tailoring variables to inform a future adaptive implementation intervention to scale IDEAL Goals; (2) estimating the cost of delivering IDEAL Goals and implementation strategies; and (3) examining the relationship between different sequences of implementation strategies on: clients’ receipt of cardiovascular disease risk factor management processes and outcomes over 18 months; and clients’ receipt of IDEAL Goals over 30 months. Qualitative efforts will explore implementation strategy mechanisms, adaptations, and participants’ experience of delivering and receiving IDEAL Goals. Discussion To meaningfully reduce premature mortality for people with serious mental illness, it is imperative to test strategies that can facilitate optimal uptake and continued sustainability of cardiovascular risk reduction programs in community settings. Trial registration ClinicalTrials.gov identifier: NCT06674616 , registered on November 1, 2024.

There is strong association of Alzheimer's disease (AD) pathology with gait disorder and falls in older adults without dementia. The goal of the study was to examine the prevalence and severity of AD pathology in older adults without dementia who fall and sustain hip fracture. Cerebrospinal fluid (CSF) was obtained from 168 hip fracture patients. CSF Aβ42/40 ratio, p-tau, and t-tau measures were dichotomized into normal vs. abnormal, and categorized according to the A/T/N classification. Among the hip fracture patients, 88.6% of the cognitively normal (Clinical Dementia Rating-CDR 0; n = 70) and 98.8% with mild cognitive impairment (CDR 0.5; n = 81) fell in the abnormal biomarker categories by the A/T/N classification. A large proportion of older hip fracture patients have CSF evidence of AD pathology. Preoperative determination of AD biomarkers may play a crucial role in identifying persons without dementia who have underlying AD pathology in perioperative settings.

OBJECTIVE: To quantify the association of treated diabetes with cancer incidence and cancer mortality as well as cancer case fatality and all-cause mortality in adults who subsequently develop cancer and to calculate attributable fractions due to diabetes on various cancer outcomes. RESEARCH DESIGN AND METHODS: Prospective data on 599 diabetic and 17,681 nondiabetic adults from the CLUE II (Give Us a Clue to Cancer and Heart Disease) cohort in Washington County, Maryland, were analyzed. Diabetes was defined by self-reported use of diabetes medications at baseline. Cancer incidence was ascertained using county and state cancer registries. Mortality data were obtained from death certificates. RESULTS: From 1989 to 2006, 116 diabetic and 2,365 nondiabetic adults developed cancer, corresponding to age-adjusted incidence of 13.25 and 10.58 per 1,000 person-years, respectively. Adjusting for age, sex, education, BMI, smoking, hypertension treatment, and high cholesterol treatment using Cox proportional hazards regression, diabetes was associated with a higher risk of incident cancer (hazard ratio 1.22 [95% CI 0.98–1.53]) and cancer mortality (1.36 [1.02–1.81]). In individuals who developed cancer, adults with diabetes had a higher risk of cancer case fatality (1.34 [1.002–1.79]) and all-cause mortality (1.61 [1.29–2.01]). For colorectal, breast, and prostate cancers, the attributable fractions resulting from diabetes were larger for cancer fatality and mortality than cancer incidence. CONCLUSIONS: In this prospective cohort, diabetes appears to exert a greater influence downstream on the risk of mortality in people with cancer than on upstream risk of incident cancer.

In the largest, longitudinal study of young, deaf children before and three years after cochlear implantation, we compared symbolic play and novel noun learning to age-matched hearing peers. Participants were 180 children from six cochlear implant centers and 96 hearing children. Symbolic play was measured during five minutes of videotaped, structured solitary play. Play was coded as \"symbolic\" if the child used substitution (e.g., a wooden block as a bed). Novel noun learning was measured in 10 trials using a novel object and a distractor. Cochlear implant vs. normal hearing children were delayed in their use of symbolic play, however, those implanted before vs. after age two performed significantly better. Children with cochlear implants were also delayed in novel noun learning (median delay 1.54 years), with minimal evidence of catch-up growth. Quality of parent-child interactions was positively related to performance on the novel noun learning, but not symbolic play task. Early implantation was beneficial for both achievement of symbolic play and novel noun learning. Further, maternal sensitivity and linguistic stimulation by parents positively affected noun learning skills, although children with cochlear implants still lagged in comparison to hearing peers.

Background Obesity is a leading cause of preventable death among individuals with serious mental illness (SMI). A prior randomized controlled trial demonstrated the efficacy of a lifestyle style intervention tailored to this population; however, such interventions need to be adapted and tested for real‐world settings. Aims This study evaluated implementation interventions to support community mental health program staff to deliver an evidence‐based lifestyle intervention to clients with obesity and SMI. Materials & Methods In this cluster‐randomized pilot trial, the standard arm combined multimodal training with organizational strategy meetings and the enhanced arm included all standard strategies plus performance coaching. Staff‐coaches delivered a 6‐month group‐based lifestyle intervention to clients with SMI. Primary outcomes were changes in staff knowledge, self‐efficacy, and fidelity scores for lifestyle intervention delivery. Linear mixed‐effects modeling was used to analyze outcomes, addressing within‐site clustering and within‐participant longitudinal correlation of outcomes. Results Three sites were in the standard arm (7 staff‐coaches); 5 sites in the enhanced arm (11 staff‐coaches). All sites delivered all 26 modules of the lifestyle intervention. Staff‐coaches highly rated the training strategy's acceptability, feasibility and appropriateness. Overall, mean knowledge score significantly increased pre‐post by 5.5 (95% CI: 3.9, 7.1) and self‐efficacy was unchanged; neither significantly differed between arms. Fidelity ratings remained stable over time and did not differ between arms. Clients with SMI achieved a mean 6‐month weight loss of 3.8 kg (95% CI: 1.6, 6.1). Conclusions Mental health staff delivering a lifestyle intervention was feasible using multicomponent implementation interventions, and preliminary results show weight reduction among clients with SMI. The addition of performance coaching did not significantly change outcomes. Future studies are needed to definitively determine the effect on client health outcomes. We conducted a pilot randomized controlled trial comparing standard and enhanced implementation interventions to facilitate community mental health program staff as coaches delivering the 6‐month behavioral weight‐loss program. We demonstrated that it is feasible for staff‐coaches to deliver this program with high fidelity when implemented with multimodal training combined with organizational strategy meetings. Individuals with SMI achieved a statistically significant 6‐month weight loss on par with the magnitude of weight reduction in the Achieving Healthy Lifestyles in Psychiatric Rehabilitation trial.

Purpose To examine the impact of cochlear implant (CI) intervention on health-related quality of life (HRQOL) assessed by both self- and parent-reported measures. Methods In this national study of children implanted between ages 6 months and 5 years, HRQOL of 129 children 6-year post-CI was compared to 62 internal study (NH1) and 185 external (NH2) samples of hearing children frequency-matched to the CI group on sociodemographic variables. HRQOL ratings of children and their parents in each group, measured using the Child Health and Illness Profile-Child Edition, were compared, and their associations with the Family Stress Scale were investigated. Results CI children reported overall and domain-specific HRQOL that was comparable to both NH1 and NH2 peers. CI parents reported worse child scores than NH1 parents in Achievement, Resilience, and Global score (p's < 0.01) but similar or better scores than socioeconomically comparable NH2 parents. Higher family stress was negatively associated with all parent-reported HRQOL outcomes (p's < 0.01). Parent–child correlations in HRQOL global scores trended higher in CI recipients (r = 0.50) than NH1 (r = 0.42) and NH2 (r = 0.35) controls. Conclusions CI recipients report HRQOL comparable to NH peers. These results, from both child and parent perspective, lend support to the effectiveness of CI intervention in mitigating the impact of early childhood deafness. Family stress was associated with worse HRQOL, under-scoring a potential therapeutic target. Parent–child agreement in HRQOL scores was higher for CI families than NH families, which may reflect higher caregiver insight and involvement related to the CI intervention.