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Background Assessment of functional ability, including activities of daily living (ADLs), is a manual process completed by skilled health professionals. In the presented research, an automated decision support tool, the Computational Barthel Index Tool (CBIT), was constructed that can automatically assess and predict probabilities of current and future ADLs based on patients’ medical history. Methods The data used to construct the tool include the demographic information, inpatient and outpatient diagnosis codes, and reported disabilities of 181,213 residents of the Department of Veterans Affairs’ (VA) Community Living Centers. Supervised machine learning methods were applied to construct the CBIT. Temporal information about times from the first and the most recent occurrence of diagnoses was encoded. Ten-fold cross-validation was used to tune hyperparameters, and independent test sets were used to evaluate models using AUC, accuracy, recall and precision. Random forest achieved the best model quality. Models were calibrated using isotonic regression. Results The unabridged version of CBIT uses 578 patient characteristics and achieved average AUC of 0.94 (0.93–0.95), accuracy of 0.90 (0.89–0.91), precision of 0.91 (0.89–0.92), and recall of 0.90 (0.84–0.95) when re-evaluating patients. CBIT is also capable of predicting ADLs up to one year ahead, with accuracy decreasing over time, giving average AUC of 0.77 (0.73–0.79), accuracy of 0.73 (0.69–0.80), precision of 0.74 (0.66–0.81), and recall of 0.69 (0.34–0.96). A simplified version of CBIT with 50 top patient characteristics reached performance that does not significantly differ from full CBIT. Conclusion Discharge planners, disability application reviewers and clinicians evaluating comparative effectiveness of treatments can use CBIT to assess and predict information on functional status of patients.

Background Symptoms arising from vestibular system dysfunction are observed in 49–59% of people with Multiple Sclerosis (MS). Symptoms may include vertigo, dizziness and/or imbalance. These impact on functional ability, contribute to falls and significant health and social care costs. In people with MS, vestibular dysfunction can be due to peripheral pathology that may include Benign Paroxysmal Positional Vertigo (BPPV), as well as central or combined pathology. Vestibular symptoms may be treated with vestibular rehabilitation (VR), and with repositioning manoeuvres in the case of BPPV. However, there is a paucity of evidence about the rate and degree of symptom recovery with VR for people with MS and vestibulopathy. In addition, given the multiplicity of symptoms and underpinning vestibular pathologies often seen in people with MS, a customised VR approach may be more clinically appropriate and cost effective than generic booklet-based approaches. Likewise, BPPV should be identified and treated appropriately. Methods/ design People with MS and symptoms of vertigo, dizziness and/or imbalance will be screened for central and/or peripheral vestibulopathy and/or BPPV. Following consent, people with BPPV will be treated with re-positioning manoeuvres over 1–3 sessions and followed up at 6 and 12 months to assess for any re-occurrence of BPPV. People with central and/or peripheral vestibulopathy will be entered into a randomised controlled trial (RCT). Trial participants will be randomly allocated (1:1) to either a 12-week generic booklet-based home programme with telephone support or a 12-week VR programme consisting of customised treatment including 12 face-to-face sessions and a home exercise programme. Customised or booklet-based interventions will start 2 weeks after randomisation and all trial participants will be followed up 14 and 26 weeks from randomisation. The primary clinical outcome is the Dizziness Handicap Inventory at 26 weeks and the primary economic endpoint is quality-adjusted life-years. A range of secondary outcomes associated with vestibular function will be used. Discussion If customised VR is demonstrated to be clinically and cost-effective compared to generic booklet-based VR this will inform practice guidelines and the development of training packages for therapists in the diagnosis and treatment of vestibulopathy in people with MS. Trial registration ISRCTN Number: 27374299 Date of Registration 24/09/2018 Protocol Version 15 25/09/2019

Background Foot orthoses and corticosteroid injection are common interventions used for plantar heel pain, however few studies have investigated the variables that predict response to these interventions. Methods Baseline variables (age, weight, height, body mass index (BMI), sex, education, foot pain, foot function, fear-avoidance beliefs and feelings, foot posture, weightbearing ankle dorsiflexion, plantar fascia thickness, and treatment preference) from a randomised trial in which participants received either foot orthoses or corticosteroid injection were used to predict change in the Foot Health Status Questionnaire foot pain and foot function subscales, and first-step pain measured using a visual analogue scale. Multivariable linear regression models were generated for different dependent variables (i.e. foot pain, foot function and first-step pain), for each intervention (i.e. foot orthoses and corticosteroid injection), and at different timepoints (i.e. weeks 4 and 12). Results For foot orthoses at week 4, greater ankle dorsiflexion with the knee extended predicted reduction in foot pain (adjusted R2 = 0.16, p = 0.034), and lower fear-avoidance beliefs and feelings predicted improvement in foot function (adjusted R2 = 0.43, p = 0.001). At week 12, lower BMI predicted reduction in foot pain (adjusted R2 = 0.33, p R2 = 0.37, p R2 0.19, p = 0.011). For corticosteroid injection at week 4, there were no significant predictors for change in foot pain or foot function. At week 12, less weightbearing hours predicted reduction in foot pain (adjusted R2 = 0.25, p = 0.004) and lower baseline foot pain predicted improvement in foot function (adjusted R2 = 0.38, p Conclusions People with plantar heel pain who use foot orthoses experience reduced foot pain if they have greater ankle dorsiflexion and lower BMI, while they experience improved foot function if they have lower fear-avoidance beliefs and lower BMI. People who receive a corticosteroid injection experience reduced foot pain if they weightbear for fewer hours, while they experience improved foot function if they have less baseline foot pain.

Background There is still controversy about the relationship between aging and changes in functional ability. This study aims to describe the level of basic activities of daily living (ADL) and higher-level instrumental activities of daily living (IADL) in different age groups and explore the factors associated with functional disability in Chinese older inpatients. Methods This cross-sectional study surveyed 9996 older inpatients aged 65 years and older from six tertiary hospitals in China from October 2018 to February 2019. The levels of ADL and IADL were measured by scores of the Barthel index and Instrumental Activities of Daily Living Scale. A mixed-effect generalized linear model was used to examine the association between functional disability and covariates. Results The average ADL score was 89.51 ± 19.29 and the mean IADL score 6.76 ± 2.01 for all participants. There was a trend of decreasing scores along with aging, and significant differences between age groups were also observed (P Conclusions Functional ability declines with aging, older inpatients are low dependency upon ADL and IADL. There are several associated factors among the participants derived from this investigation of a large-scale, multicenter, nationally representative Chinese older inpatient population. These findings potentially have major importance for the planning of hospital services, discharge planning, and post-discharge care. Trial registration Chinese Clinical Trial Registry, ChiCTR1800017682, registered August 9, 2018.

Background Although malnutrition risk is well documented in elderly care institutions, few studies have been conducted to address concerns regarding community-dwelling elderly people. This study has been aimed to describe the nutritional status and its related socioeconomic and geriatric factors in community-dwelling elders with malnutrition. Method For this study, a randomized sampling among people aged 60 has been done (n = 326). Information on nutrition status (full MNA) and health information, like cognitive status (MMSE), daily functional status (ADL and IADL scales) and frailty was obtained. Multiple logistic regression analyses have been carried out, in order to identify the association of demographical and clinical factors with malnutrition. Results 28.1% of the participants suffered from poor nutrition. In the binary analysis, low MNA scores were associated with increasing age, female gender, lower education level, financial dependence, solitary life, poor self-rated health, multiple physical disabilities and chronic disease, polypharmacy, smoking, functional and cognitive decrease and frailty. In the final model of the multivariate analysis, living alone (OR:1.249,CI:1.105–2.620), multiple physical disabilities (OR:2.183,CI:1.246 ± 3..250) and chronic disease (OR: 2.148,CI:1.167–2.879) were independently associated with malnutrition. Also financial independency (OR:0.625,CI:0.233–0.938), functional ability on ADL (OR:0.536,CI:0.327–0.976) and IADL (OR:0.319,CI:0.194–0.856), normal cognitive (OR:0.456,CI:0.293–0.934) and no frailty (OR:0.253,CI:0.117–0.729) independently were inversely associated with malnutrition. The model was adjusted for all socio- demographic and health variables that were significantly related in the previous models. Conclusions Our results indicated a strong correlation between malnutrition and health status. Identifying predictive factors can potentially improve prevention and management strategies used for malnutrition in elderly.

The prevalence of hallux valgus (HV) increases with age in females. Several studies have investigated the relationship between foot problems, including HV, and falls in older individuals. This study aimed to examine whether HV causes a decline in functional activity in young females and also evaluate the relationship between HV angle, functional activity, toe flexor strength, and plantar pressure. We assessed 94 females (mean age, 19.6 ± 1.3 years; mean body mass index, 21.2 ± 2.0 kg/m2) not currently receiving treatment for lower limb disease. HV angle was determined using their footprint. Functional reach (FR) and maximum step length (MSL), toe flexor strength, and plantar pressure were measured. Plantar pressure was measured during walking. We also calculated FR and the pressure in eight regions (first toe, second through fifth toes, first metatarsal, second through fourth metatarsals, fifth metatarsal, midfoot, medial heel, and lateral heel). There were 39 and 55 participants in the HV and no HV groups, respectively. FR and MSL did not differ significantly between the HV and no HV groups. Toe flexor strength was significantly different between the HV and no HV groups (26.69 ± 9.68 vs. 32.19 ± 8.55, respectively) (p = 0.002, β = 0.206). During walking, plantar pressure was significantly lower in the second through fifth toes in the HV group (p = 0.005, β = 0.187). During FR, plantar pressure was significantly greater in the first metatarsal in the HV group (p = 0.016, β = 0.338). HV angle was negatively correlated with toe flexor strength (r = − 0.315, p = 0.002, β = 0.121) and plantar pressure during walking in the second through fifth toes (r = − 0.362, p

Background Despite the enormous financial and humanistic burden of chronic low back pain (CLBP), there is little consensus on what constitutes the best treatment options from a multitude of competing interventions. The objective of this network meta-analysis (NMA) is to determine the relative efficacy and acceptability of primary care treatments for non-specific CLBP, with the overarching aim of providing a comprehensive evidence base for informing treatment decisions. Methods We will perform a systematic search to identify randomised controlled trials of interventions endorsed in primary care guidelines for the treatment of non-specific CLBP in adults. Information sources searched will include major bibliographic databases (MEDLINE, Embase, CENTRAL, CINAHL, PsycINFO and LILACS) and clinical trial registries. Our primary outcomes will be patient-reported pain ratings and treatment acceptability (all-cause discontinuation), and secondary outcomes will be functional ability, quality of life and patient/physician ratings of overall improvement. A hierarchical Bayesian class-based NMA will be performed to determine the relative effects of different classes of pharmacological (NSAIDs, opioids, paracetamol, anti-depressants, muscle relaxants) and non-pharmacological (exercise, patient education, manual therapies, psychological therapy, multidisciplinary approaches, massage, acupuncture, mindfulness) interventions and individual treatments within a class (e.g. NSAIDs: diclofenac, ibuprofen, naproxen). We will conduct risk of bias assessments and threshold analysis to assess the robustness of the findings to potential bias. We will compute the effect of different interventions relative to placebo/no treatment for both short- and long-term efficacy and acceptability. Discussion While many factors are important in selecting an appropriate intervention for an individual patient, evidence for the analgesic effects and acceptability of a treatment are key factors in guiding this selection. Thus, this NMA will provide an important source of evidence to inform treatment decisions and future clinical guidelines. Systematic review registration PROSPERO registry number: CRD42019138115

Background Asylum seekers and refugees (AS&Rs) experience impaired mental health and wellbeing, related to stresses in their country of origin, experiences in transit and reception on arrival, including significant barriers to accessing mainstream services. Their contact with health care is often crisis-driven and mediated through non-governmental organisations (NGOs). Problem Management Plus (PM+) is a psychosocial intervention recommended by the World Health Organisation to address distress experienced by adults affected by humanitarian crises. We are investigating its application for the first time in a high-income country. Methods In a pilot randomised controlled trial (RCT), PM+ will be delivered to AS&Rs in contact with NGOs in Liverpool City Region, UK by lay therapists who have lived experience of forced migration. Following systematic review and stakeholder engagement, PM+ has been adapted to the local context, and lay therapists have been trained in its delivery. We will assess the feasibility of conducting a three-arm RCT of five 90-min sessions of PM+, delivered individually or in groups by lay therapists to AS&Rs experiencing emotional distress and functional impairment, compared with each other and with usual support offered by local NGOs. Distress and impairment at baseline will be measured by the Hospital Anxiety and Depression Scale (HADS) and the WHO Disability Assessment Schedule (WHO-DAS). We aim to recruit 105 participants, 35 per arm. Primary health outcomes are anxiety and depressive symptoms at 3 months, measured by HADS. Secondary outcomes include subjective wellbeing, functional status, progress on identified problems, presence of post-traumatic stress disorder and depressive disorder and service usage. Longer-term impact will be assessed at 6 months post baseline, on the same parameters. We will assess the feasibility of conducting a full RCT in relation to the following elements: recruitment and retention of lay therapists and study participants; fidelity of delivery of PM+; and suitability of the study measures, including any linguistic or cultural barriers. Discussion We will use these findings to specify the parameters for a full RCT to test the effectiveness and cost-effectiveness of PM+ in reducing emotional distress and health inequalities, and improving functional ability and wellbeing, amongst asylum seekers and refugees. Trial registration ISRCTN, ID: ISRCTN15214107. Registered on 10 September 2019.

Background Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease, predominantly affecting joints, which is initially treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). In RA patients with insufficient response to csDMARDs, the addition of prednisone or tocilizumab, a biological DMARD (bDMARD), to the medication has been shown to be effective in reducing RA symptoms. However, which of these two treatment strategies has superior effectiveness and safety is unknown. Methods In this multicenter, investigator-initiated, open-label, randomized, pragmatic trial, we aim to recruit 120 RA patients meeting the 2010 ACR/EULAR classification criteria for RA, with active disease defined as a Clinical Disease Activity Index (CDAI) > 10 and at least one swollen joint of the 28 assessed. Patients must be on stable treatment with csDMARDs for ≥ 8 weeks prior to screening and must have been treated with ≥ 2 DMARDs, of which a maximum of one tumor necrosis factor inhibitor (a class of bDMARDs) is allowed. Previous use of other bDMARDs or targeted synthetic DMARDs is not allowed. Patients will be randomized in a 1:1 ratio to receive either tocilizumab (subcutaneously at 162 mg/week) or prednisone (orally at 10 mg/day) as an addition to their current csDMARD therapy. Study visits will be performed at screening; baseline; and months 1, 2, 3, 6, 9, and 12. Study medication will be tapered in case of clinical remission (CDAI ≤ 2.8 and ≤ 1 swollen joint at two consecutive 3-monthly visits) with careful monitoring of disease activity. In case of persistent high disease activity at or after month 3 (CDAI > 22 at any visit or > 10 at two consecutive visits), patients will switch to the other strategy arm. Primary outcome is a change in CDAI from baseline to 12 months. Secondary outcomes are additional clinical response and quality of life measures, drug retention rate, radiographically detectable progression of joint damage, functional ability, and cost utility. Safety outcomes include tocilizumab-associated adverse events (AEs), glucocorticoid-associated AEs, and serious AEs. Discussion This will be the first randomized clinical trial comparing addition of oral prednisone or of tocilizumab head to head in RA patients with insufficient response to csDMARD therapy. It will yield important information for clinical rheumatology practice. Trial registration This trial was prospectively registered in the Netherlands Trial Register on October 7, 2019 (NL8070). The Netherlands Trial Register contains all items from the World Health Organization Trial Registration Data Set.

Background Dementia is a neurological condition that affects the cognitive and functional ability of the brain and is the leading cause of disability among those aged 65 years and above. More effective ways to manage dementia symptoms are needed because current treatment options (antidepressants and antipsychotics) can be ineffective and are associated with substantial side effects, including increased rate of mortality. Cannabinoid-based medicine (CBM) has shown an ability to inhibit some symptoms associated with dementia, and the adverse effects are often minimal; yet, little research has explored the use of CBM among this population. Aim To monitor the safety of a purified dose of CBM oil (3:2 delta-9-tetrahydrocannabinol:cannabidiol) on behaviour symptoms, quality of life and discomfort caused by pain. Methods/design We will carry out an 18-week, randomised, double-blind crossover trial that consists of a 2-week eligibility period, two 6-week treatment cycles, and two 2-week washout periods (between both cycles and after the second treatment cycle). We aim to recruit 50 participants with dementia who are living in residential aged-care facilities. The participants will be randomised into two groups and will receive a dose of either CBM oil or placebo for the first treatment cycle and the opposite medication for the second. Data will be collected using the Neuropsychiatric Inventory Questionnaire, the Cohen-Mansfield Agitation Inventory, the Quality of Life in Alzheimer’s Disease questionnaire, and the Abbey Pain Scale on seven occasions. These will be completed by the participants, aged-care staff, and nominated next of kin or family members. The participants’ heart rate and blood pressure will be monitored weekly, and their body composition and weight will be monitored fortnightly by a research nurse, to assess individual dose response and frailty. In addition, pre- and post-surveys will be administered to aged-care staff and family members to understand their perceptions of CBM and to inform proposed focus groups consisting of the aged-care staff and next of kin. Discussion The study design has been informed by medical professionals and key stakeholders, including those working in the residential aged-care industry to ensure patient safety, collection of non-invasive measures, and methodological rigor and study feasibility. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12619000474156. Registered on 21 March 2019

Background Fatigue is an important clinical finding in patients with chronic hepatitis virus infection. However, studies assessing fatigue in patients with chronic hepatitis B (CHB) are very limited. This study aimed to quantify the severity of fatigue in patients with CHB, to determine whether perceived fatigue reflects impairment of functional ability, and to explore potential causes. Methods A total of 133 patients with histologically proven CHB and 59 community controls were assessed using the fatigue impact scale (FIS). Results The degree of fatigue was significantly higher in patients with CHB than in controls (mean (range) FIS 24.9 (0–91) vs. 15.7 (0–31), p

Background No previous studies have characterized a patient’s experience of rheumatoid arthritis (RA) management in Greece and unmet needs may exist despite a broad range of available treatments. Therefore, we assessed quality of life (QoL), functional ability, and healthcare resource utilization in patients with established RA and receiving treatment in a tertiary care setting in Greece. Methods This was a prospective, observational cohort of patients aged ≥18 years, receiving any type of treatment for RA, and followed for 12 months at 7 rheumatology referral centers across mainland Greece (NCT01001182). Patient data were collected at the initial visit and 3, 6, and 9 months. QoL was evaluated using the Euro Quality of Life-5 dimensions questionnaire (EQ-5D) and functional ability was evaluated using the Health Assessment Questionnaire (HAQ). Results A total of 210 patients with RA were enrolled (76.7% women, mean ± standard deviation [SD] age: 59.1 ± 12.6 years, median [interquartile range] disease duration: 11.9 [5.0–16.0] years). Baseline mean ± SD EQ-5D and HAQ scores were 0.57 ± 0.32 and 0.75 ± 0.63, respectively, and remained largely unchanged throughout the study. Post-hoc comparison showed that patients receiving non-biologic disease-modifying antirheumatic drugs (non-bDMARDs) had significantly higher EQ-5D and lower HAQ-DI scores compared with those receiving biologic DMARDs. A majority of patients reported having difficulty doing housework or other duties (61.4 and 61.9%, respectively), and 55.2% reported needing external support for these tasks. Positive correlation was observed between QoL and functional ability. Hospitalization at least once during the study occurred in 9.5% of the patients, and 12.5% of these cases were due to exacerbation of RA. At baseline, 52.4% of the patients were retired, with 38.5% of retirees having retired early due to RA. Among the patients who were retired at baseline, the mean ± SD period from actual retirement to expected retirement age was 12.1 ± 8.1 years. Conclusion QoL and functional ability were positively correlated in patients with long-standing RA, with a large proportion showing impairments in both. Timely, target-oriented treatment initiated as soon as possible after diagnosis may help to improve patient-reported outcomes and limit the burden of RA. Trial registration ClinicalTrials.gov NCT01001182. Registered 23 October 2009. Electronic supplementary material The online version of this article (10.1186/s12955-019-1127-8) contains supplementary material, which is available to authorized users.

Background In the absence of a consensus on definition and measurement of healthy ageing, we created a healthy ageing index tallying with the functional ability framework provided by the World Health Organization. To create this index, we employed items of functional ability and intrinsic capacity. The current study aims to establish the predictive validity and discrimination properties of this healthy ageing index in settings in Latin American, part of the 10/66 cohort. Methods Population-based cohort studies including 12,865 people ≥65 years old in catchment areas of Cuba, Dominican Republic, Venezuela, Mexico and Peru. We employed latent variable modelling to estimate the healthy ageing scores of each participant. We grouped participants according to the quintiles of the healthy ageing score distribution. Cox’s proportional hazard models for mortality and sub-hazard (competing risks) models for incident dependence (i.e. needing care) were calculated per area after a median of 3.9 years and 3.7 years, respectively. Results were pooled together via fixed-effects meta-analysis. Our findings were compared with those obtained from self-rated health. Results Participants with lowest levels, compared to participants with highest level of healthy ageing, had increased risk of mortality and incident dependence, even after adjusting for sociodemographic and health conditions (HR: 3.25, 95%CI: 2.63–4.02; sub-HR: 5.21, 95%CI: 4.02–6.75). Healthy ageing scores compared to self-rated health had higher population attributable fractions (PAFs) for mortality (43.6% vs 19.3%) and incident dependence (58.6% vs 17.0%), and better discriminative power (Harrell’s c-statistic: mortality 0.74 vs 0.72; incident dependence 0.76 vs 0.70). Conclusion These results provide evidence that our healthy ageing index could be a valuable tool for prevention strategies as it demonstrated predictive and discriminative properties. Further research in other cultural settings will assist moving from a theoretical conceptualisation of healthy ageing to a more practical one.

Background Acute hospital services account for the largest proportion of health care system budgets, and older adults are the most frequent users. As a result, older people who have been recently discharged from hospital may be at greater risk of readmission. This study aims to evaluate the comparative effectiveness of transitional care interventions on unplanned hospital readmissions within 28 days, 12 weeks and 24 weeks following hospital discharge. Method The present study was a randomised controlled trial (ACTRN12608000202369). The trial involved 222 participants who were recruited from medical wards in two metropolitan hospitals in Australia. Participants were eligible for inclusion if they were aged 65 years and over, admitted with a medical diagnosis and had at least one risk factor for readmission. Participants were randomised to one of four groups: standard care, exercise program only, Nurse Home visit and Telephone follow-up (N-HaT), or Exercise program and Nurse Home visit and Telephone follow-up (ExN-HaT). Socio-demographics, health and functional ability were assessed at baseline, 28 days, 12 weeks and 24 weeks. The primary outcome measure was unplanned hospital readmission which was defined as any hospital admission for an unforeseen or unplanned cause. Results Participants in the ExN-HaT or the N-HaT groups were 3.6 times and 2.6 times respectively significantly less likely to have an unplanned readmission 28 days following discharge (ExN-HaT group HR 0.28, 95% CI 0.09–0.87, p = 0.029; N-HaT group HR 0.38, 95% CI 0.13–1.07, p = 0.067). Participants in the ExN-HaT or the N-HaT groups were 2.13 and 2.63 times respectively less likely to have an unplanned readmission in the 12 weeks after discharge (ExN-HaT group HR 0.47, 95% CI 0.23–0.97, p = 0.014; N-HaT group HR 0.38, 95% CI 0.18–0.82, p = 0.040). At 24 weeks after discharge, there were no significant differences between groups. Conclusion Multifaceted transitional care interventions across hospital and community settings are beneficial, with lower hospital readmission rates observed in those receiving more transitional intervention components, although only in first 12 weeks. Trial registration Australian and New Zealand Clinical Trial Registry (ACTRN12608000202369).

Background Despite decades of study, debates exist surrounding the relationship between education and functional health status transition among elderly populations. This study aims to add evidence to the debates using China as a case study. Specifically, this study analysed the association of education with functional health status transition and then the mechanism behind that association using the budget constraint relax hypothesis and the efficiency improvement hypothesis among elderly population in China. Methods Based on data from the Chinese Longitudinal Healthy Longevity Surveys from 2008 and 2011, this study focussed on adults aged 65 years and above, with a final sample size of 12,112. A generalised structural equation model was used to analyse the relationship between education and functional health status transition and the mechanism behind that association. Results During the three examined years, among elderly adults who were nondisabled at baseline, 53.1% stayed nondisabled, 14.6% became disabled, and 32.3% died; among those disabled in 2008, 8.1% recovered, 21.6% stayed disabled, and 70.3% died. Compared with older adults without any education, those who had attended primary schools had both lower mortality and disability, whereas those who had attended high schools and above only had a lower mortality rate. The budget constraint relax hypothesis and the efficiency improvement hypothesis explained the majority of the relationship between education and transition from non-disability to death, but hardly explained the transition from non-disability to disability. Furthermore, once a person was disabled, education had no significant relationship with functional ability recovery or mortality. Conclusions Attending primary school seems to provide the highest benefit to functional health status transition among older and nondisabled persons in China. Those who attended high schools and above are expected to live a longer life with disability. The mechanism between education and the onset of disability needs more discussion.

Background Oral functional ability decreases with age, and systemic immunological ability and quality of life can also deteriorate. Continuous moderate whole-body exercise for older people is known to improve oral functional and their immunological abilities. Here, we evaluated the effect of oral exercise as an alternative training method for highly older people who cannot perform whole-body exercises. Methods Unstimulated whole saliva samples had been collected for three times before training as baseline data and one time after 3 and 6 weeks of training each. Participants were instructed to conduct self-massage; their tongues were used to press their orbicularis oris muscle and buccinators, and instructed to perform bilateral massage of three major glands for facilitating saliva secretion. Medical histories, daily life habits and characteristics were also collected. Results Totally 30 participants (84.2 ± 8.5 years) were enrolled. In contrast to previous researches, increase in salivary Immunoglobulin A (IgA) after the training was not observed. Interestingly, hierarchical clustering analyses revealed clear individual variations as two prominent clusters and a strong positive correlation between stimulated saliva flow rate and IgA flow rate, regardless of the continuous oral functional exercise. Only body mass index (BMI) showed significant differences between the two groups (Z = 2.06, P = 0.039, Wilcoxon rank-sum test) among all collected parameters. Conclusion Oral functional training limitedly effects on salivary parameters of highly older people. On the other hand, BMI characterized salivary features more than any other parameters, such as the presence of diseases or medication use in these people. Trial registration: UMIN-CTR Clinical Trial UMIN000028394 on 27/July 2017, retrospectively registered.

Background Myocardium regeneration in adult mammals is very limited, but has enormous therapeutic potentials. However, we are far from complete understanding the cellular and molecular mechanisms by which heart tissue can regenerate. The full functional ability of amphibians to regenerate makes them powerful animal models for elucidating how damaged mature organs are naturally reconstituted in an adult organism. Like other amphibians, such as newts and axolotls, adult Xenopus displays high regenerative capacity such as retina. So far, whether the adult frog heart processes regenerative capacity after injury has not been well delineated. Results We examined the regeneration of adult cardiac tissues of Xenopus tropicalis after resection of heart apex. We showed, for the first time, that the adult X. tropicalis heart can regenerate perfectly in a nearly scar-free manner approximately 30 days after injury via apical resection. We observed that the injured heart was sealed through coagulation immediately after resection, which was followed by transient fibrous tissue production. Finally, the amputated area was regenerated by cardiomyocytes. During the regeneration process, the cardiomyocytes in the border area of the myocardium adjacent to the wound exhibited high proliferation after injury, thus contribute the newly formed heart tissue. Conclusions Establishing a cardiac regeneration model in adult X. tropicalis provides a powerful tool for recapitulating a perfect regeneration phenomenon and elucidating the underlying molecular mechanisms of cardiac regeneration in an adult heart, and findings from this model may be applicable in mammals. Electronic supplementary material The online version of this article (10.1186/s13578-017-0199-6) contains supplementary material, which is available to authorized users.

Background Treatment of recurrent aggressive fibromatosis (AF) following surgical resection is a clinical challenge. Non-steroidal anti-inflammatory drugs (NSAIDs) have been reported to be an effective option for controlling the disease. However, long-term NSAID use can result in unfavorable complications. This study was a trial of the use of intralesional steroid injection (ILSI) including investigation of safety margins and clinical outcomes of high-dose steroids for local use treatment of AF. Methods A prospective cohort study was conducted to evaluate the safety and efficacy of particulate corticosteroids for AF. Intralesional steroid injections of Kanolone® guided by ultrasound were given monthly for three consecutive months with 1 mg/kg/episode (a total of 3 mg/kg). Patients were followed up monthly for 3 months at the time of each monthly injection and then for an additional 3 months after the last injection. Complications from the procedure and clinical outcomes were monitored. Results Eight recurrent AF patients completed the full 6-month evaluation process. No procedure-related complications were reported either during the injection period or the follow-up period. None of the patients developed Cushingoid features. The highest number of complication events, all of which were mild or detectable only by laboratory analysis, occurred during the month following the second injection. Triamcinolone levels were significantly increased 24 h after injection, and four of the eight cases developed hypothalamic-pituitary-axis suppression. Tumors were stabilized in 83.3% of the cases during the study period, and pain and functional ability scores improved significantly. Conclusions Intralesional steroid injection appears to be a safe and effective alternative treatment for recurrent AF. Trial registration TCTR20150409001; Registered date: 9 April 2015; The safety and result of intratumoral steroid injection for aggressive fibromatosis. Electronic supplementary material The online version of this article (10.1186/s12957-017-1262-9) contains supplementary material, which is available to authorized users.

Background Aquatic therapy promotes short-term benefits for patients with knee osteoarthritis (OA), and it may be the first therapeutic option for this pathological condition. The objective of this study was to investigate the effects of an aquatic therapy program on pain intensity, functional ability, and quality of life in older people with knee OA. Methods/design This is a parallel, two-arm, open, randomized controlled clinical trial with older people with knee OA. Volunteers will be allocated to an aquatic intervention group (WG), subjected to the intervention, or to a control group, not be subjected to any kind of intervention. Data collection pre- and postintervention will be composed of the evaluation of the perception of pain by visual analogue scale with application of nociceptive stimuli in four anatomical points of the knee, functional fitness tests, and application of the World Health Organization Quality of Life Scale abbreviated version and Western Ontario and McMaster Universities Osteoarthritis Index. The program will last 12 weeks, consisting of aerobic and functional exercises in the form of circuit training. Discussion The objective of this clinical trial is to evaluate the effect of aquatic therapy in elderly patients with knee OA. The study is guided by practice-based scientific evidence for the use of aquatic rehabilitation exercises. It is expected that the WG volunteers will show reduced pain intensity, increased flexibility, and improved functional capacity and quality of life. It is believed that the desired results can be attributed to physical and physiological effects of immersion in warm water associated with the exercise protocol proposed. The data will be published after completion of the study. Trial registration Brazilian Registry of Clinical Trials (ReBEC) registration number: RBR-78h48d. Registered on 19 August 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2061-x) contains supplementary material, which is available to authorized users.

Background This qualitative study examined how individuals with Spinal Muscular Atrophy (SMA), their caregivers, and clinicians defined meaningful change, primarily in the Type II and non-ambulant type III patient populations, associated with treatment of this condition. In addition, we explored participants’ views about two measures of motor function routinely used in clinical trials for these SMA subtypes, namely the expanded version of the Hammersmith Functional Motor Scale (HFMSE) and the Upper Limb Module (ULM). Methods The 123 participants (21 with SMA, 64 parents, and 11 clinicians), recruited through SMA advocacy organizations, participated in one of 16 focus groups or 37 interviews. The sessions were audio-recorded, and verbatim transcripts were analyzed using a grounded theory approach. Results For the participants, meaningful change was relative to functional ability, and small changes in motor function could have an important impact on quality of life. Because patients and families feared progressive loss of functional ability, the participants saw maintenance of abilities as a meaningful outcome. They believed that measures of motor function covered important items, but worried that the HFMSE and ULM might not be sensitive enough to capture small changes. In addition, they felt that outcome measures should assess other important features of life with SMA, including the ability to perform daily activities, respiratory function, swallowing, fatigue, and endurance. Conclusions Given the heterogeneity of SMA, it is important to expand the assessment of treatment effects to a broader range of outcomes using measures sensitive enough to detect small changes.

Background Muscular strength is associated with functional ability in elderly, and older adults are recommended to perform muscle-strengthening exercise. Understanding how improved muscle strength and -mass influence general and specific domains of quality of life is important when planning health promotion efforts targeting older adults. The aims of the present study were to describe changes in health-related quality of life (HRQOL) in older men participating in 12 weeks of systematic strength training, and to investigate whether improvements in muscle strength and muscle mass are associated with enhancements in HRQOL. Methods We recruited 49 men aged 60–81 years to participate in an intervention study with pre-post assessment. The participants completed a 12-week strength training program consisting of three sessions per week. Tests and measurements aimed at assessing change in HRQOL, and changes in physical performance (maximal strength) and physiological characteristics. HRQOL was measured using the 12-item short-form survey (SF-12). Muscle mass was assessed based on changes in lean mass (leg, trunk, arm, and total), and strength was measured as one-repetition maximum in leg extension, leg press, and biceps curl. Results Two of the eight HRQOL SF-12 scores, role physical and general health, and the physical component summary scores, increased significantly during the intervention period. Small significant positive correlations were identified between improvements in muscle strength, and better physical and social function. Moreover, a significant increase in total muscle mass was seen during the intervention period. Conclusions The positive, findings from this study would suggest that systematic strength training seems to be a beneficial intervention to improve HRQOL, muscle strength and muscle mass in older men. © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Background The Scottish Early Rheumatoid Arthritis (SERA) study is an inception cohort of rheumatoid (RA) and undifferentiated arthritis (UA) patients that aims to provide a contemporary description of phenotype and outcome and facilitate discovery of phenotypic and prognostic biomarkers Methods Demographic and clinical outcome data are collected from newly diagnosed RA/UA patients every 6 months from around Scotland. Health service utilization data is acquired from Information Services Division, NHS National Services Scotland. Plain radiographs of hands and feet are collected at baseline and 12 months. Additional samples of whole blood, plasma, serum and filtered urine are collected at baseline, 6 and 12 months Results Results are available for 1073 patients; at baseline, 76 % were classified as RA and 24 % as UA. Median time from onset to first review was 163 days (IQR97-323). Methotrexate was first-line DMARD for 75 % patients. Disease activity, functional ability and health-related quality of life improved significantly between baseline and 24 months, however the proportion in any employment fell (51 to 38 %, p = 0.0005). 24 % patients reported symptoms of anxiety and/or depression at baseline. 35/391 (9 %) patients exhibited rapid radiographic progression after 12 months. The SERA Biobank has accrued 60,612 samples Conclusions In routine care, newly diagnosed RA/UA patients experience significant improvements in disease activity, functional ability and health-related quality of life but have high rates of psychiatric symptoms and declining employment rates. The co-existence of a multi-domain description of phenotype and a comprehensive biobank will facilitate multi-platform translational research to identify predictive markers of phenotype and prognosis Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1318-y) contains supplementary material, which is available to authorized users.

Background This study aimed to explore differences in links between negative symptoms and neurocognitive deficits in adolescent and adult patients with first-episode schizophrenia. Schizophrenia is a mental disorder often characterized by positive and negative symptoms, reduced emotional expression, excitatory status, and poor cognitive ability. The severity of negative symptoms in patients with schizophrenia was reported to be more related to poor quality of life, weak functional ability, and heavy burden from families than with the severity of positive symptoms. Previous studies suggested correlations between the severity of negative symptoms in patients with schizophrenia and neurocognitive deficits. Methods This study included 92 patients (33 adolescents and 59 adults) with first-episode schizophrenia and 57 healthy people matched by age and education level. Neurocognitive functions and clinical symptoms were assessed using a standardized questionnaire. Results Patients with first-episode schizophrenia showed neurocognitive deficits in most neuropsychological assessments compared with healthy people. With the variable of education level controlled, the negative factor score of adolescent patients with first-episode schizophrenia was strongly correlated with more time spent in part 1 (r = .646) and part 2 (r = .663) of the trail making test, and moderately correlated to more perseverative errors (r = .425) of the Wisconsin card sorting test and fewer correct trials 2 (r = −.425) of the continuous performance test. However, no such correlations were found in adult patients. Conclusions This study indicated significant correlations between negative symptoms and most neurocognitive functions in patients with first-episode schizophrenia, with a stronger correlation in adolescent patients. Trial registration The trial registration number is ChiCTR-COC-14005302 , while retrospectively registered on January 5, 2014.

Background Foot surgery is common in RA but the current lack of understanding of how patients interpret outcomes inhibits evaluation of procedures in clinical and research settings. This study aimed to explore which factors are important to people with RA when they evaluate the outcome of foot and ankle surgery. Methods and Results Semi structured interviews with 11 RA participants who had mixed experiences of foot surgery were conducted and analysed using thematic analysis. Responses showed that while participants interpreted surgical outcome in respect to a multitude of factors, five major themes emerged: functional ability, participation, appearance of feet and footwear, surgeons’ opinion, and pain. Participants interpreted levels of physical function in light of other aspects of their disease, reflecting on relative change from their preoperative state more than absolute levels of ability. Appearance was important to almost all participants: physical appearance, foot shape, and footwear were closely interlinked, yet participants saw these as distinct concepts and frequently entered into a defensive repertoire, feeling the need to justify that their perception of outcome was not about cosmesis. Surgeons’ post-operative evaluation of the procedure was highly influential and made a lasting impression, irrespective of how the outcome compared to the participants’ initial goals. Whilst pain was important to almost all participants, it had the greatest impact upon them when it interfered with their ability to undertake valued activities. Conclusions People with RA interpret the outcome of foot surgery using multiple interrelated factors, particularly functional ability, appearance and surgeons’ appraisal of the procedure. While pain was often noted, this appeared less important than anticipated. These factors can help clinicians in discussing surgical options in patients. Electronic supplementary material The online version of this article (doi:10.1186/s13047-016-0153-6) contains supplementary material, which is available to authorized users.

Background: Vascular health is of concern in patients with Juvenile Idiopathic Arthritis (JIA) since Rheumatoid Arthritis (RA) epidemiologically has a well-described association with premature development of atherosclerosis. Chronic inflammation with persisting systemic circulating inflammatory proteins may be a cause of vascular damage, but general physical inactivity could be an important contributor. Pain and fatigue are common complaints in patients with JIA and may well lead to an inactive sedentary lifestyle. For this reason we assessed the physical activity (PA) objectively in patients with moderate to severe Juvenile Idiopathic Arthritis (JIA) in comparison with gender and age matched healthy schoolchildren, and looked for associations between PA and features of JIA. Methods: One hundred thirty-three patients, 7-20 years of age, participated. Disease activity, disability, functional ability, and pain were assessed and PA was measured by accelerometry through 7 days and compared to PA in age-and gender-matched healthy schoolchildren. Results: We found a significantly lower level of PA in patients compared to gender-and age-matched healthy schoolchildren both in average activity (counts per minute, cpm) (475.6 vs. 522.7, p = 0.0000018) and in minutes per day spent with cpm > 1500 (67.9 vs. 76.4, p = 0.0000014), with cpm > 2000 (moderate physical activity) (48.4 vs. 52.8, p = 0.0001, and with cpm > 3000 (high physical activity) (24.7 vs. 26.5, p = 0.00015). A negative association (beta = -0.213, p = 0.014) between active disease in weight bearing joints and high physical activity remained the only significant association between disease related factors and PA. Of the girls 19 % and of the boys 45 % (vs. 39 % and 61 % in the reference group) met standards set by Danish Health Authorities for daily PA in childhood. Conclusion: Children and adolescents with JIA are less physically active than their healthy peers and less active than recommended for general health by the Danish Health Authorities. This is not explained by pain or objective signs of inflammation. When inflammation has been curbed, restoration of an active healthy lifestyle should be highly prioritized.