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Type IVa choledochal cysts: surgical management and literature review

Thambi Dorai CR, Visvanathan R, McAll GL

Aust N Z J Surg, 1991 Jul;61(7):505-10.
PMID: 1859310

Type IVa choledochal cysts with cylindrical dilatation of the intrahepatic ducts constitute a relatively less recognized variety of choledochal cysts, and differ from cystic dilatation of intrahepatic ducts in their clinical manifestations and response to treatment. Five patients with type IVa choledochal cysts and cylindrical dilatation of major intrahepatic ducts who underwent cyst excision and Roux-en-Y hepaticojejunostomy are reported. The duration of symptoms was less than 1 year in all patients. Palpable abdominal mass and abdominal pain were present in 3 patients. The traid of jaundice, abdominal pain and mass was present in only 1 patient. The intrahepatic dilatation regressed after excision of the extrahepatic cyst just below the hilum of the liver. The surgical technique is described and the need for excision of the cyst is emphasized.
Do dysplastic and adenomatous changes in large bowel hamartomas predispose to malignancy?--A report of two cases

Visvanathan R, Thambidorai CR, Myint H

Ann Acad Med Singap, 1992 Nov;21(6):830-2.
PMID: 1338270

Two patients, members of one family, with Peutz-Jeghers syndrome are described who underwent surgery for bowel obstruction. Both had multiple polyps in the gastrointestinal tract. Severe dysplasia and adenomatous change were present in two hamartomatous polyps adjacent to a stenosing colonic carcinoma in one patient and moderate dysplasia and adenomatous change were observed in two hamartomatous rectal polyps in his son. These changes support recent reports in the literature of progression towards neoplasia in these lesions.
Fulltext An unusual injury to the mediastinum--case report

Visvanathan R

Singapore Med J, 1992 Dec;33(6):639-40.
PMID: 1488681

A six-year-old boy sustained an accidental penetrating missile injury to his chest. Imaging studies revealed a metallic foreign body lodged between the pulmonary infundibulum and the right atrium of the heart. No cardiovascular compromise was produced. Surgical exploration was not required. The foreign body remained stable and non-migratory over a 16-month follow-up period.
Blunt abdominal trauma--injury assessment in relation to early surgery

Visvanathan R, Low HC

J R Coll Surg Edinb, 1993 Feb;38(1):19-22.
PMID: 8437147

One hundred and thirteen patients sustaining blunt abdominal trauma over a 24-month period were retrospectively divided into three groups to assess parameters of three diagnostic methods and the time-lapse before implementing surgical treatment. Diagnosis was based in group A patients (n = 20) on physical findings, plain radiology, and blood and urine examinations. Diagnostic methods in group B patients (n = 35) and in group C patients (n = 58) were as in group A but with the addition of diagnostic peritoneal lavage (DPL) in group B or with the addition of diagnostic abdominal ultrasonography (DAU) in group C. Sixty-five patients underwent abdominal exploration. The time-lag from commencement of examination to surgery was 332.33 +/- 48.90 min, 251.82 +/- 29.08 min and 570.89 +/- 133.80 min respectively in groups A, B and C. It was significantly shorter in group B compared with group C (P = 0.03). DPL had a sensitivity of 95%, a specificity of 81% and an accuracy of 89% whilst DAU had a sensitivity of 79%, a specificity of 85% and an accuracy of 83% in detecting significant injury. The conclusion is that DPL in combination with DAU would facilitate early assessment and treatment of intra-abdominal injuries.
Spectrum of cholangitis in a rural setting in North-eastern Peninsular Malaysia

Khan TF, Raj SM, Visvanathan R

Trop Doct, 1993 Jul;23(3):117-8.
PMID: 8356738
Fulltext Ascarid worms causing recurrent cholangitis in a patient with an obstructing ampullary tumour

Khan TF, Zahari A, Sherazi ZA, Visvanathan R

Singapore Med J, 1993 Oct;34(5):462-3.
PMID: 8153702

This is a report of a 57-year-old Malay lady who presented with recurrent episodes of cholangitis and septicaemia. A dilated biliary tree caused by a stenosing periampullary tumour was found to contain adult round worms. A pancreatico-duodenectomy was performed following biliary decompression. Ascarid worms are a rare cause of cholangitis in malignant biliary obstruction.
Fulltext Primary closure following drainage of a rectus sheath muscle abscess

Visvanathan R

Singapore Med J, 1994 Feb;35(1):108-9.
PMID: 8009268

The primary closure of a rectus sheath muscle abscess was performed on an 11-year-old child following evacuation of its contents under antimicrobial cover. Complete healing was achieved in eight days. This method avoids the delays in wound healing and morbidity associated with conventional drainage and shortens convalescence.
Helicobacter pylori infection in north-eastern peninsular Malaysia. Evidence for an unusually low prevalence

Uyub AM, Raj SM, Visvanathan R, Nazim M, Aiyar S, Anuar AK, et al.

Scand. J. Gastroenterol., 1994 Mar;29(3):209-13.
PMID: 8209178

The prevalence of Helicobacter pylori infection was determined in peptic ulcer patients, in non-ulcer dyspepsia (NUD) patients, and in the general adult population. The H. pylori infection rate ascertained by microbiologic examination of multiple gastric antral biopsy specimens was 50% (17 of 34) in duodenal ulcer (DU), 5% (1 of 22) in gastric ulcer, and 9% (15 of 159) in NUD patients. A seroepidemiologic survey showed a prevalence of only 4.2% among 496 blood donors and 4.8% among 921 subjects who attended health screening clinics. H. pylori infection is relatively uncommon and does not appear to be the predominant factor in the pathogenesis of peptic ulcer disease in the area. The incidence of peptic ulcer perforations in the area in 1991-92 was 1.5 per 100,000 person-years, reflecting a relatively low frequency of peptic ulcers, which might be due to the low prevalence of H. pylori infection in the population.
Severe head injury management in a general surgical department

Visvanathan R

Aust N Z J Surg, 1994 Aug;64(8):527-9.
PMID: 8048888

Sixty-nine severely head-injured patients treated by general surgeons over a 28 month period with admission Glasgow Coma Scale motor scores of 3 to 8 were reviewed retrospectively. Fifty-one patients were comatose on admission with periods from injury to admission exceeding 4 h in 34 patients who were referred from peripheral hospitals. Forty patients with acute intracranial bleeding underwent emergency decompressive surgery with 13 good recoveries and 18 deaths; good recoveries were observed in 11 of 20 patients with extradural haemorrhages, one out of eight patients with subdural haemorrhages, and one of 12 patients with intracerebral and/or combined haemorrhages. Twenty-nine patients with no evidence of acute mass lesions were treated medically with sedation, mechanical ventilation and mannitol infusion for cerebral decompression with seven good recoveries and 16 deaths. There were 15 good outcomes in 40 patients with admission motor scores of 6, 7 or 8 and five good outcomes in 29 patients with scores of 3, 4 or 5. A good outcome of 29% in the study may be improved by (i) better neurosurgical training of surgical and nursing staff; (ii) provision of technologically advanced diagnostic and treatment modalities; (iii) an efficient referral system; and (iv) provision of effective long-term rehabilitation.
Fulltext The nutritional status of 1081 elderly people residing in publicly funded shelter homes in Peninsular Malaysia

Visvanathan R, Zaiton A, Mohd Sidik S, Muhamad YA

Eur J Clin Nutr, 2005 Mar;59(3):318-24.
PMID: 15523487

OBJECTIVES: The aim of this study was to determine the: (1) prevalence of undernutrition as determined by the 'DETERMINE Your Nutritional Health Checklist' (NHC) and (2) factors independently associated with undernutrition among the older residents of these publicly funded shelter homes in Peninsular Malaysia.
DESIGN: A total of 1081 elderly people (59%M) over the age of 60 y were surveyed using questionnaires determining baseline demographics, nutritional and cognitive status, physical function and psychological well-being.
SETTING: Shelter homes, Peninsular Malaysia.
RESULTS: In all, 41.4% (n = 447) were nourished (score <3), 32.1% (n = 347) at moderate risk (score between 3 and 5) and 26.6% (n = 287) were at high risk of undernutrition (score>5) according to the NHC. A large proportion of subjects were underweight with 14.3% of subjects recording a low body mass index (BMI) <18.5 kg/m2 and a further 18.2% recording a BMI between 18.5 and 20 kg/m2. The residential geriatric depression score (GDS-12R) (relative risk (RR) = 1.03 (95% confidence interval (CI) 1.01-1.05); P = 0.002) and the number of illnesses (RR = 1.14 (95% CI 1.07-1.21); P < 0.001) were found to be independently associated with nutritional risk (NHC score > or = 3). Using a BMI < 18.5 kg/m2 as an objective marker for nutritional risk, the NHC was shown to have a sensitivity of 66.4% (95% CI 58.0-74.2%), specificity of 42.7% (95% CI 39.3-46.1%), positive predictive value of 16.2% (95% CI 13.3-19.5%) and a negative predictive value of 88.4% (95% CI 84.9-91.4%).
CONCLUSIONS: Many elderly people residing in publicly funded shelter homes in Malaysia may be at-risk of undernutrition, and were underweight. The NHC is better used as an awareness tool rather than as a screening tool.
Fulltext Good oral health, adequate nutrient consumption and family support are associated with a reduced risk of being underweight amongst older Malaysian residents of publicly funded shelter homes

Visvanathan R, Ahmad Z

Asia Pac J Clin Nutr, 2006;15(3):400-5.
PMID: 16837433

A low body mass index in older people has been associated with increased mortality. The main objective of this study was to identify factors associated with low body mass indices [ BMIs] (< 18.5 kg/m2) in older residents of shelter care facilities in Peninsular Malaysia. 1081 elderly people (59% M) over the age of 60 years were surveyed using questionnaires determining baseline demographics, nutritional and cognitive status, physical function and psychological well being. Body mass index was also determined. Subjects were recruited from publicly funded shelter homes in Peninsular Malaysia. 14.3% of residents had BMIs < 18.5 kg/m2. Multivariate analyses (adjusted for age and sex) revealed that having no family (RR 1.98[95%CI 1.40-2.82], p<0.001) and negative responses to statement 3 [I eat few fruits or vegetables or milk products] (RR 0.62 [95% CI 0.42-0.90]; P= 0.013) and statement 5 [I have tooth or mouth problems that make it hard for me to eat] (RR 0.69 [95%CI 0.50-0.96]; P= 0.023) of the ' Determine Your Nutritional Health Checklist' were independently associated with low BMIs (<18.5 kg/m2). Older people with no family support were at risk of becoming underweight. Older people who consumed fruits, vegetables or milk or had good oral health were less likely to be underweight. Nutrient intake, oral health and social support were important in ensuring healthy body weight in older Malaysians.
Fulltext Prevalence of Falls among Older People attending a Primary Care Clinic in Kuala Lumpur, Malaysia

Sazlina, S.G., Krishnan, R., Shamsul, A.S., Zaiton, A., Visvanathan, R.

Malaysian Journal of Community Health, 2008;14(1):11-0.
MyJurnal

Introduction : The aim of this study was to determine the prevalence and the pattern of falls in community dwelling older people attending a primary care clinic in Kuala Lumpur, Malaysia.
Methods : A cross sectional study was conducted in an urban primary care clinic. Participants aged 60 years and older were included in the study. A structured questionnaire, assessing socio-demographic variables, medical and falls history was administered by one investigator over a 3-month period in 2004.
Results : A total of 151 respondents participated in this study with a response rate of 72%. The prevalence of falls was 47.0% over the previous 12-months period. Fifty-seven percent reported experiencing recurrent falls. Majority (61%) of falls occurred in the home and the two most common places were the bathroom (27%) and stairs (27%). Sixty-one percent of older people who fell, sustained an injury and most sought medical attention.
Conclusion : In conclusion, falls are common amongst older people attending this primary care clinic. It occurred commonly in the home in the bathroom and near stairs. However, a larger local community study is warranted to determine the prevalence and risk factors for falls in Malaysia.

Study site: primary care clinic in Kuala Lumpur, Malaysia
Fulltext Development of a Scalable Testbed for Mobile Olfaction Verification

Zakaria SM, Visvanathan R, Kamarudin K, Yeon AS, Md Shakaff AY, Zakaria A, et al.

Sensors (Basel), 2015;15(12):30894-912.
PMID: 26690175 DOI: 10.3390/s151229834

The lack of information on ground truth gas dispersion and experiment verification information has impeded the development of mobile olfaction systems, especially for real-world conditions. In this paper, an integrated testbed for mobile gas sensing experiments is presented. The integrated 3 m × 6 m testbed was built to provide real-time ground truth information for mobile olfaction system development. The testbed consists of a 72-gas-sensor array, namely Large Gas Sensor Array (LGSA), a localization system based on cameras and a wireless communication backbone for robot communication and integration into the testbed system. Furthermore, the data collected from the testbed may be streamed into a simulation environment to expedite development. Calibration results using ethanol have shown that using a large number of gas sensor in the LGSA is feasible and can produce coherent signals when exposed to the same concentrations. The results have shown that the testbed was able to capture the time varying characteristics and the variability of gas plume in a 2 h experiment thus providing time dependent ground truth concentration maps. The authors have demonstrated the ability of the mobile olfaction testbed to monitor, verify and thus, provide insight to gas distribution mapping experiment.
Fulltext The state of nutrition care in outpatient hemodialysis settings in Malaysia: a nationwide survey

Khor BH, Chinna K, Abdul Gafor AH, Morad Z, Ahmad G, Bavanandam S, et al.

BMC Health Serv Res, 2018 Dec 04;18(1):939.
PMID: 30514284 DOI: 10.1186/s12913-018-3702-9

BACKGROUND: This study aimed to assess the situational capacity for nutrition care delivery in the outpatient hemodialysis (HD) setting in Malaysia by evaluating dietitian accessibility, nutrition practices and patients' outcomes.
METHODS: A 17-item questionnaire was developed to assess nutrition practices and administered to dialysis managers of 150 HD centers, identified through the National Renal Registry. Nutritional outcomes of 4362 patients enabled crosscutting comparisons as per dietitian accessibility and center sector.
RESULTS: Dedicated dietitian (18%) and visiting/shared dietitian (14.7%) service availability was limited, with greatest accessibility at government centers (82.4%) > non-governmental organization (NGO) centers (26.7%) > private centers (15.1%). Nutritional monitoring varied across HD centers as per albumin (100%) > normalized protein catabolic rate (32.7%) > body mass index (BMI, 30.7%) > dietary intake (6.0%). Both sector and dietitian accessibility was not associated with achieving albumin ≥40 g/L. However, NGO centers were 36% more likely (p = 0.030) to achieve pre-dialysis serum creatinine ≥884 μmol/L compared to government centers, whilst centers with dedicated dietitian service were 29% less likely (p = 0.017) to achieve pre-dialysis serum creatinine ≥884 μmol/L. In terms of BMI, private centers were 32% more likely (p = 0.022) to achieve BMI ≥ 25.0 kg/m2 compared to government centers. Private centers were 62% less likely (p
Fulltext The Pictorial Fit-Frail Scale: Developing a Visual Scale to Assess Frailty

Theou O, Andrew M, Ahip SS, Squires E, McGarrigle L, Blodgett JM, et al.

Can Geriatr J, 2019 Jun;22(2):64-74.
PMID: 31258829 DOI: 10.5770/cgj.22.357

Background: Standardized frailty assessments are needed for early identification and treatment. We aimed to develop a frailty scale using visual images, the Pictorial Fit-Frail Scale (PFFS), and to examine its feasibility and content validity.
Methods: In Phase 1, a multidisciplinary team identified domains for measurement, operationalized impairment levels, and reviewed visual languages for the scale. In Phase 2, feedback was sought from health professionals and the general public. In Phase 3, 366 participants completed preliminary testing on the revised draft, including 162 UK paramedics, and rated the scale on feasibility and usability. In Phase 4, following translation into Malay, the final prototype was tested in 95 participants in Peninsular Malaysia and Borneo.
Results: The final scale incorporated 14 domains, each conceptualized with 3-6 response levels. All domains were rated as "understood well" by most participants (range 64-94%). Percentage agreement with positive statements regarding appearance, feasibility, and usefulness ranged from 66% to 95%. Overall feedback from health-care professionals supported its content validity.
Conclusions: The PFFS is comprehensive, feasible, and appears generalizable across countries, and has face and content validity. Investigation into the reliability and predictive validity of the scale is currently underway.
Translation, adaptation and pilot testing of the Pictorial Fit-Frail Scale (PFFS) for use in Malaysia - The PFFS-Malay version (PFFS-M)

Ahip SS, Shariff-Ghazali S, Lukas S, Abdul Samad A, Mustapha UK, Theou O, et al.

Malays Fam Physician, 2021 Jul 22;16(2):27-36.
PMID: 34386161 DOI: 10.51866/oa1036

Background: Frailty is an important health issue in an aging population; it is a state of vulnerability that renders the elderly susceptible to adverse health outcomes, including disability, hospitalization, long-term care admission and death. Early frailty stages are recognizable through screening and are reversible with targeted interventions. To date, however, there is no screening tool for use in Malaysia. The English Pictorial Fit-Frail Scale (PFFS) is a visual tool that assesses a person's fitness-frailty level in 14 health domains, with higher scores indicating higher frailty.
Objective: The aim was to translate and adapt the English PFFS for use in Malaysian clinical settings.
Methods: The original English PFFS underwent forward and backward-translation by two bilingual translators to and from the Malay language. A finalized version, the PFFS-Malay (PFFS-M), was formed after expert reviewers' consensus and was pilot tested with 20 patients, 20 caregivers, 16 healthcare assistants, 17 nurses and 22 doctors. Score agreement between patients and their caregivers and among healthcare professionals were assessed. All participants rated their understanding of the scale using the feasibility survey forms.
Results: A total of 95 participants were included. There were high percentages of scoring agreements among all participants on the scale (66.7% to 98.9%). Overall feedback from all respondents were positive and supported the face validity of the PFFS-M.
Conclusion: The PFFS-M reflects an accurate translation for the Malaysian population. The scale is usable and feasible and has face validity. Reliability and predictive validity assessments of the PFFS-M are currently underway.
Fulltext A multicentre, multi-national, double-blind, randomised, active-controlled, parallel-group clinical study to assess the safety and efficacy of PDA10 (Epoetin-alpha) vs. Eprex® in patients with anaemia of chronic renal failure

Lim SK, Goh BL, Visvanathan R, Kim SH, Jeon JS, Kim SG, et al.

BMC Nephrol, 2021 Nov 25;22(1):391.
PMID: 34823497 DOI: 10.1186/s12882-021-02601-w

BACKGROUND: Erythropoietin stimulating agent (ESA) has been standard of care in treating renal anaemia for the past 20 years. Many patients have limited access to ESA in view of long-term costs leading to suboptimal ESA dosage. Biosimilar epoetin is a potential cost-effective alternative to originator for optimal renal anaemia management.
OBJECTIVE: To determine efficacy and safety of PDA10 in treating renal anaemia in haemodialysis patients, in comparison to the originator epoetin-α, Eprex®.
METHODS: A phase 3, multicentre, multi-national, double-blind, randomised, active-controlled and parallel group study conducted over 40 weeks in Malaysia and Korea. End stage kidney disease patients undergoing regular haemodialysis who were on erythropoietin treatment were recruited. The study has 3 phases, which included a 12-week titration phase, followed by 28-week double-blind treatment phase and 24-week open-label extension phase.
RESULTS: The PDA10 and Eprex® were shown to be therapeutically equivalent (p
Fulltext Muscle Status Response to Oral Nutritional Supplementation in Hemodialysis Patients With Protein Energy Wasting: A Multi-Center Randomized, Open Label-Controlled Trial

Sahathevan S, Karupaiah T, Khor BH, Sadu Singh BK, Mat Daud ZA, Fiaccadori E, et al.

Front Nutr, 2021;8:743324.
PMID: 34977109 DOI: 10.3389/fnut.2021.743324

Background: Muscle wasting, observed in patients with end-stage kidney disease and protein energy wasting (PEW), is associated with increased mortality for those on hemodialysis (HD). Oral nutritional supplementation (ONS) and nutrition counseling (NC) are treatment options for PEW but research targeting muscle status, as an outcome metric, is limited. Aim: We compared the effects of combined treatment (ONS + NC) vs. NC alone on muscle status and nutritional parameters in HD patients with PEW. Methods: This multi-center randomized, open label-controlled trial, registered under ClinicalTrials.gov (Identifier no. NCT04789031), recruited 56 HD patients identified with PEW using the International Society of Renal Nutrition and Metabolism criteria. Patients were randomly allocated to intervention (ONS + NC, n = 29) and control (NC, n = 27) groups. The ONS + NC received commercial renal-specific ONS providing 475 kcal and 21.7 g of protein daily for 6 months. Both groups also received standard NC during the study period. Differences in quadriceps muscle status assessed using ultrasound (US) imaging, arm muscle area and circumference, bio-impedance spectroscopy (BIS), and handgrip strength (HGS) methods were analyzed using the generalized linear model for repeated measures. Results: Muscle indices as per US metrics indicated significance (p < 0.001) for group × time interaction only in the ONS + NC group, with increases by 8.3 and 7.7% for quadriceps muscle thickness and 4.5% for cross-sectional area (all p < 0.05). This effect was not observed for arm muscle area and circumference, BIS metrics and HGS in both the groups. ONS + NC compared to NC demonstrated increased dry weight (p = 0.039), mid-thigh girth (p = 0.004), serum prealbumin (p = 0.005), normalized protein catabolic rate (p = 0.025), and dietary intakes (p < 0.001), along with lower malnutrition-inflammation score (MIS) (p = 0.041). At the end of the study, lesser patients in the ONS + NC group were diagnosed with PEW (24.1%, p = 0.008) as they had achieved dietary adequacy with ONS provision. Conclusion: Combination of ONS with NC was effective in treating PEW and contributed to a gain in the muscle status as assessed by the US, suggesting that the treatment for PEW requires nutritional optimization via ONS.
Fulltext Correction to: A multicentre, multi-national, double-blind, randomised, active-controlled, parallel-group clinical study to assess the safety and efficacy of PDA10 (Epoetin-Alfa) vs. Eprex® in patients with anaemia of chronic renal failure

Lim SK, Goh BL, Visvanathan R, Kim SH, Jeon JS, Kim SG, et al.

BMC Nephrol, 2022 Jan 03;23(1):14.
PMID: 34979969 DOI: 10.1186/s12882-021-02651-0
Screening, Diagnosis and Management of Sarcopenia and Frailty in Hospitalized Older Adults: Recommendations from the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Expert Working Group

Daly RM, Iuliano S, Fyfe JJ, Scott D, Kirk B, Thompson MQ, et al.

J Nutr Health Aging, 2022;26(6):637-651.
PMID: 35718874 DOI: 10.1007/s12603-022-1801-0

Sarcopenia and frailty are highly prevalent conditions in older hospitalized patients, which are associated with a myriad of adverse clinical outcomes. This paper, prepared by a multidisciplinary expert working group from the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR), provides an up-to-date overview of current evidence and recommendations based on a narrative review of the literature for the screening, diagnosis, and management of sarcopenia and frailty in older patients within the hospital setting. It also includes suggestions on potential pathways to implement change to encourage widespread adoption of these evidence-informed recommendations within hospital settings. The expert working group concluded there was insufficient evidence to support any specific screening tool for sarcopenia and recommends an assessment of probable sarcopenia/sarcopenia using established criteria for all older (≥65 years) hospitalized patients or in younger patients with conditions (e.g., comorbidities) that may increase their risk of sarcopenia. Diagnosis of probable sarcopenia should be based on an assessment of low muscle strength (grip strength or five times sit-to-stand) with sarcopenia diagnosis including low muscle mass quantified from dual energy X-ray absorptiometry, bioelectrical impedance analysis or in the absence of diagnostic devices, calf circumference as a proxy measure. Severe sarcopenia is represented by the addition of impaired physical performance (slow gait speed). All patients with probable sarcopenia or sarcopenia should be investigated for causes (e.g., chronic/acute disease or malnutrition), and treated accordingly. For frailty, it is recommended that all hospitalized patients aged 70 years and older be screened using a validated tool [Clinical Frailty Scale (CFS), Hospital Frailty Risk Score, the FRAIL scale or the Frailty Index]. Patients screened as positive for frailty should undergo further clinical assessment using the Frailty Phenotype, Frailty Index or information collected from a Comprehensive Geriatric Assessment (CGA). All patients identified as frail should receive follow up by a health practitioner(s) for an individualized care plan. To treat older hospitalized patients with probable sarcopenia, sarcopenia, or frailty, it is recommended that a structured and supervised multi-component exercise program incorporating elements of resistance (muscle strengthening), challenging balance, and functional mobility training be prescribed as early as possible combined with nutritional support to optimize energy and protein intake and correct any deficiencies. There is insufficient evidence to recommend pharmacological agents for the treatment of sarcopenia or frailty. Finally, to facilitate integration of these recommendations into hospital settings organization-wide approaches are needed, with the Spread and Sustain framework recommended to facilitate organizational culture change, with the help of 'champions' to drive these changes. A multidisciplinary team approach incorporating awareness and education initiatives for healthcare professionals is recommended to ensure that screening, diagnosis and management approaches for sarcopenia and frailty are embedded and sustained within hospital settings. Finally, patients and caregivers' education should be integrated into the care pathway to facilitate adherence to prescribed management approaches for sarcopenia and frailty.

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