Association between serum copper, zinc and hospital admissions among care home residents

Nutritional status is important in various health care settings, long-term care is no exception. The relationship between protein-energy malnutrition and clinical outcomes in care homes has been reported. However, little is known about the roles of trace elements in clinical outcomes of care home residents. In 2002, 75 severely disabled care home residents (mean age: 77.7 ± 8.2 years, 64.3% males) were enrolled for study. The status of protein-energy malnutrition at enrollment was as follows: 47.9% underweight (body mass index, BMI < 20 kg/m²), 15.5% hypoalbuminemia (serum albumin <3.5 mg/dl), and 29.6% hypocholesterolemia (serum total cholesterol <160 mg/dl), respectively. During the 6-month follow-up, anthropometric measurements (i.e., BMI and mid-arm circumferences) remained similar, but the biochemical markers of nutritional status (i.e., albumin, total cholesterol) were significantly deteriorated, and both serum zinc and copper were significantly increased. Compared with subjects without hospitalizations during the follow-up period, subjects ever hospitalized had significantly lower mean serum levels of albumin (3.6 ± 0.3 mg/dl vs. 3.9 ± 0.3 mg/dl, p = 0.002), zinc (74.3 ± 12.1 vs. 89.6 ± 20.5 μg/dl, p = 0.020), and higher serum levels of copper (110.6 ± 14.1 vs. 95.2 ± 21.1 μg/dl, p = 0.023) at baseline screening. Adjusted for age, sex, and protein-energy malnutrition, baseline serum copper (odds ratio = OR = 1.08, 95% CI = 1.02-1.15, p = 0.015) and zinc (OR = 0.92, 95% CI = 0.84-1.00, p = 0.053) were significant independent predictive factor for hospital admissions. In conclusion, adjusted for age, sex, and protein-energy malnutrition, serum levels of copper and zinc both were independent predictive factors for hospitalizations among care home residents. Further interventional study is needed to clarify the prognostic roles of serum copper and zinc among care home residents.     

Risk factors of potentially inappropriate medications among older patients visiting the community health center in rural Taiwan

The adverse drug reactions caused by potentially inappropriate medications (PIMs) are closely related to emergency department visits and acute hospital admissions in the elderly population. It has been reported that 11.5-14% of community-dwelling elderly patients were prescribed for at least one PIM, but little is known regarding to it in rural Taiwan. The purpose of this study was to evaluate the prevalence and risk factors of PIMs among older patients visiting the outpatient clinic of a community health center in rural Taiwan. In August of 2008, all elderly patients attended the outpatient clinic of a community health center in I-Lan County were enrolled for study. PIMs are evaluated by Beers’ criteria. In total, 327 patients (mean age: 74.8 ± 5.3 years old, 49.5% males) were enrolled, and 27.5% (90/327) of them were prescribed for at least one PIM. The most common PIMs were antihistamines (50.9%) and muscle relaxants (39.0%). In particular, 87.6% of these PIMs were having a high severity potential. Patients had PIMs were significantly older (76.2 ± 6.9 vs. 74.2 ± 6.1 years, p = 0.011), being prescribed for more drugs (3.7 ± 1.4 vs. 2.4 ± 1.7 items, p < 0.001), and more commonly to visit due to acute diseases (64.4% vs. 24.9%, p < 0.001) than those had no PIM. Multiple logistic regression showed that older age (OR = 1.05, 95% CI = 1.00-1.09, p = 0.046), higher number of prescribed medications (OR = 1.66, 95% CI = 1.39-1.98, p < 0.001), and diagnosis of acute diseases (OR = 8.98, 95% CI = 4.71-17.10, p < 0.001) are all independent risk factors for PIMs. In conclusion, the prevalence of PIMs in the outpatient clinic of the community health care center in rural Taiwan was 27.5%. Older age, higher number of prescribed medications and diagnosis of acute diseases are independent risk factors for PIMs in rural Taiwan.     

Care utilisation in the last years of life in Sweden: the effects of gender and marital status differ by type of care

The effects of gender and marital status on care utilisation in the last years of life are highly correlated. This study analysed whether gender differences in use of eldercare (home help services or institutional care) or hospital care in the last 5 years of life, and the place of death, could be attributed to differences in marital status and thereby to potential access to informal care. A longitudinal Swedish study provided register data on 567 participants (aged 83 +) who died between 1995 and 2004. A higher proportion of unmarried than married people used home help services; this was true of both men and women. The likelihood of receiving home help was lower for those living with their spouse (OR = 0.38) and for those with children (OR = 0.60). In the 2 years preceding death, the proportion receiving home help services decreased and the proportion in institutional care increased. Women were significantly more likely to die in institutional care (OR = 1.88) than men. Although men were less likely to live in institutional care than women and more likely to be inpatients in the 3 months preceding death, after controlling for residence in institutional care, neither gender nor marital status was statistically significant when included in the same model. In summary, the determining factor for home help utilisation seemed to be access to informal care, whereas gender differences in health status could explain women’s higher probability of dying in institutional care.     

Cancer in home care: Unintended weight loss and ethical challenges. A cross-sectional study of older people at 11 sites in Europe

The aim of this study was to compare unintended weight loss in cancer patients to other elderly. Home care users, aged ≥65 from urban areas at 11 sites in Europe (N = 4010) were assessed with the Resident Assessment Instrument for Home Care. Epidemiological and medical characteristics of clients and service utilization were recorded. A total of 321 (8%) patients had a cancer diagnosis; they were on average 80.4 ± 7.3 years. Socio-demographic, functional and clinical parameters revealed small variations in the two groups. Compared to the non-cancer group, they more frequently suffered from: severe malnutrition (odds ratio = OR = 2.4) unintended weight loss (OR = 2.0), had been hospitalized during the last 6 months (OR = 1.8). Older patients with cancer suffer more frequently from problems associated with nutrition than non-cancer patients. A comprehensive assessment could lead to better management of food and fluid supply based on basic ethical principles.     

Predictors of clock drawing test (CDT) performance in elderly patients attending an internal medicine outpatient clinic: a pilot study on sun exposure and physical activity

Influence of sun exposure and physical activity on cognition has not been evaluated simultaneously. We aimed to evaluate predictors of clock drawing test (CDT) performance on n = 125 patients attending an internal medicine outpatient clinic. Interview data was gathered on sociodemographic, health-related and lifestyle factors referring to the last year. Factors associated with obtaining a score >0 and a full score (10/10) were analyzed by univariate (UVA) and multivariate (MVA) logistic regression analyses. Mean age of the participants was 72 ± 5, 58% were women and 17% were illiterate. Mean CDT score was 4.70 ± 2.27, 61.6% scored >0 and 21.6% scored 10/10. Both duration of walking and summer sun exposure predicted a CDT score >0 in UVA. However only summer sun exposure was an independent predictor (odds ratio = OR = 1.73, 95% confidence interval = CI = 1.16-2.57). Other factors independently associated with obtaining a score >0 were education level (OR = 2.70, 95%CI = 1.77-4.12) and cerebrovascular disease (CVD) history (OR = 0.08, 95%CI = 0.008-0.78). Factors independently associated with obtaining a full score were weight (OR = 1.05, 95%CI = 1.00-1.10), education level (OR = 2.04, 95%CI = 1.38-3.00) and visiting the clinic alone (OR = 3.92, 95%CI = 1.354-11.39). Our study shows that CDT can be utilized to unravel the lifestyle factors associated with cognitive function. To our knowledge, this is the first study to suggest an association between sun exposure and cognition.     

Prognostic impact of pre-operative albumin on short-term mortality and complications in patients with hip fracture

Low serum albumin may have prognostic value for morbidity and mortality in patients with hip fracture. The primary aim of the study was to evaluate the independent association between low serum albumin (<35 g/l) at hospital admission and short-term (in-hospital) mortality and post-operative complications of patients with hip fracture. We reviewed a prospective population-based cohort of 583 hip fracture patients who had pre-operative albumin values measured at hospital admission in one of the 3 tertiary hospitals in Northern Alberta, Canada. Patients with a primary diagnosis of hip fracture and 65 years or older were included. The primary outcomes were in-hospital mortality and any pre-specified post-operative complication. Mean serum albumin level was 33.8 ± 4.5 g/l (±S.D.), and overall 55% (n = 318) of patients had a low albumin. The in-hospital mortality was 8% (n = 46) and rate of any non-fatal post-operative complication rate was 31/100. Mortality was 11% (n = 35) among those with low albumin levels and 4% (n = 11) for those with normal values (unadjusted odds ratio (OR) 2.86, 95% CI = 1.42-5.74). After multivariate adjustment, the association between low serum albumin and mortality remained large and statistically significant (adjusted OR = 2.44, 95% confidence interval (CI) = 1.17-5.12). Low albumin levels were also significantly associated with post-operative medical complications (adjusted OR = 1.96, 95% CI = 1.36-2.83). We conclude that routine measurement of serum albumin provides valuable prognostic information for treating this frail population.     

Association of home care needs and functional recovery among community-dwelling elderly hip fracture patients

The aim of this study was to assess the home care needs and task difficulty of community-dwelling aged hip fracture and the association of functional recovery with care received. A cohort of hip fracture patients admitted to orthopedic wards for surgery was collected from August 2009 to December 2010. Patients transferred to long-term care facilities after surgery were excluded. Functional status (feeding, clothing, grooming, bathing, getting in/out of bed, walking, toileting, standing up/sitting down, and walking up/down stairs) and task difficulty for caregivers were recorded at discharge, one week and one month after discharge. In total, 116 patients (mean age: 79.4 ± 8.5 years, 51.7% males) were enrolled. The mean age of primary caregivers was 53.4 ± 14.2 years, and most were daughters or sons (54.3%), spouses (34.5%) or foreign workers (11.0%). The most common care needs were wound care (95.7%), medical visits (94.8%), cleaning and maintaining living quarters (92.2%) and vigilance to ensure patient safety (92.2%). The care needs and task difficulty significantly correlated with physical function before, one week and one month after discharge (r = −0.530, p < 0.001; r = −0.326, p = 0.001; r = −0.432, p < 0.001; r = −0.684, p < 0.001; and r = −0.475, p < 0.001, respectively). The complex and taxing home care needs of community-dwelling elderly hip fracture patients were significantly associated with functional recovery. Comprehensive geriatric assessment and related special medical services may greatly help caregivers and promote the practice of aging in place. Further study is needed to develop appropriate caregiver education to promote the functional recovery of elderly hip fracture patients at home.     

Impact of nutritional status on long-term functional outcomes of post-acute stroke patients in Taiwan

Nutritional status is important in stroke care, but little is known regarding to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. The main purpose of this study was to evaluate to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. Data of acute stroke registry in Kaohsiung Veterans General Hospital were retrieved for analysis. Overall, 483 patients (mean age = 70.7 ± 10.3 years) with first-ever stroke were found. Among them, 95 patients (19.7%) were malnourished at admission, 310 (mean age = 70.4 ± 10.1 years, 63.5% males) survived for 6 months, and 244 (78.7%) had good functional outcomes. Subjects with poor functional outcomes were older (74.7 ± 8.9 vs. 69.0 ± 10.1 years, p < 0.001), more likely to be malnourished (56.2% vs. 26.6%, p < 0.001), to develop pneumonia upon admission (23.3% vs. 12.7%, p = 0.027), had a longer hospital stay (23.5 ± 13.9 vs. 12.5 ± 8.2 days, p < 0.001), had a higher National Institutes of Health Stroke Scale (NIHSS) score (12.9 ± 9.3 vs. 4.9 ± 4.3, p < 0.001), poorer stroke recovery (NIHSS improvement: 6.9% vs. 27.4%, p = 0.005), and poorer functional improvement (Barthel index = BI improvement in the first month: 31.4% vs. 138%, p < 0.001). Older age (odds ratio = OR) = 1.07, 95% confidence interval (CI = 1.03-1.11, p < 0.001), baseline NIHSS score (OR = 1.23, 95%CI = 1.15-1.31, p < 0.001) and malnutrition at acute stroke (OR = 2.57, 95%CI: 1.29-5.13, p < 0.001) were all independent risk factors for poorer functional outcomes. In conclusion, as a potentially modifiable factor, more attentions should be paid to malnutrition to promote quality of stroke care since the acute stage.     

Depression, hypertension, and comorbidity: Disentangling their specific effect on disability and cognitive impairment in older subjects

We aimed to demonstrate that depression and hypertension are associated independently of each other with disability and cognitive impairment in older subjects and that such an association is not attributable to number and severity of comorbidities. An observational study was performed on elderly patients admitted to the Hospital Network of the Italian National Research Center on Aging (INRCA) from January 2005 to December 2006. Depression was defined according to 15-item geriatric depression scale (GDS) score; physical disability according to activities of daily living (ADL) and instrumental activities of daily living (IADL) scores; cognitive impairment on the mini-mental state examination (MMSE) test; the number and severity of comorbidities by means of physician-administered cumulative illness rating scale (CIRS). Among 6180 older subjects (age = 79.3 ± 5.8 years; 47% men), 48.3% were normotensive, 21.8% normotensive depressed, 21.7% hypertensive, and 8.2% hypertensive and depressed. Both depression and hypertension remained significantly associated with functional disability and cognitive impairment. When controlling for age, gender, the number and severity of comorbidities, hypertension was associated with a significantly higher likelihood of having functional disability or cognitive impairment only in the presence of depression (odds ratio = OR = 2.02, 95% confidence interval = 95%CI = 1.60-2.54, p < 0.001 for functional disability; OR = 2.21, 95%CI = 1.79-2.74, p < 0.001 for cognitive impairment) as compared to normotensive controls without depression. We conclude that depression per se’ or co-occurrence of hypertension and depression is associated with higher functional disability and cognitive impairment in older subjects. This effect is not attributable to the number or to the severity of comorbidities.     

Transient variations of transthoracic impedance as a predictor of heart failure and death in patients with implanted defibrillators

Background

Transient variations in physiological parameters may forewarn of life-threatening cardiac events, but are difficult to identify clinically. Implantable cardioverter defibrillators (ICD) designed to measure transthoracic impedance provide a surrogate marker for pulmonary congestion.

Objective

The aim of this study is to determine if the frequency of changes in transthoracic impedance (TTI) is associated with congestive heart failure (CHF) exacerbation and predicts mortality.

Methods

We followed 109 consecutive patients (pts) with ICDs (n = 58) or CRT-ICDs (n = 51) for a mean of 21.3 (+ 10.2) months. Using 80 ohm-days as a reference, we correlated the frequency of TTI changes above this index to CHF hospitalizations or death.

Results

There was at least one TTI threshold crossing in 79 (72%) pts over 23.3 months follow-up, with a mean of 1.8 ± 3.4 per year. There were 18 pts with CHF hospitalizations who had a mean of 4.3 TTI threshold crossings/year (S.D. = ± 7.3; median = 2.8), compared to 1.3 (S.D. = ± 1.5; median = 0.8) among pts without CHF hospitalizations (p = 0.0006). Among 20 patients who died during follow-up, there were 4.2 (S.D. = ± 7.0; median = 2.9) TTI threshold crossings/year, compared with 1.3 (S.D. = ± 1.3; median = 0.9) threshold crossings/year among survivors (p = 0.0004). Using Cox Proportional Hazard modeling, after adjusting for age, baseline EF, and number of shocks, TTI threshold crossing was an independent predictor of death (HR 1.72, 95% CI 1.26–2.36, p = 0.001).

Conclusions

Increased frequency of TTI threshold crossings may be a useful predictor of transient risk for identifying a subgroup of ICD recipients at greater individual risk for death or CHF hospitalizations.     

Hemodynamic effects of Ivabradine in addition to dobutamine in patients with severe systolic dysfunction

Background

Dobutamine induced tachycardia increases myocardial oxygen consumption and impairs ventricular filling. We hypothesized that Ivabradine may be efficient to control dobutamine induced tachycardia.

Methods

We assessed the effects of Ivabradine in addition to dobutamine in stable heart failure (HF) patients (LVEF < 35%, n = 22, test population) and validated its effects in refractory cardiogenic shock patients (n = 9, validation population) with contraindication to cardiac assistance or transplant. In the test population (62 ± 17 years, LVEF = 24 ± 8%), systolic and diastolic function were assessed at rest and under dobutamine [10γ/min], before and after Ivabradine [5 mg per os]. In the validation population (54 ± 11 years, LVEF = 22 ± 7%), Ivabradine [5 mg twice a day] was added to the dobutamine infusion.

Results

In the test population, Ivabradine decreased heart rate [HR] at rest and during dobutamine echocardiography (− 9 ± 8 bpm, P = 0.0004). The decrease in HR was associated with a decrease in cardiac power output and an increase in diastolic duration at rest (+ 74 ± 67 ms, P = 0.0002), and during dobutamine infusion (+ 75 ± 67 ms, P < 0.0001). Change in LVEF during dobutamine was greater after Ivabradine treatment than before (+ 7.2 ± 4.7% vs. + 3.6 ± 4.2%, P = 0.002). In the validation population, Ivabradine decreased HR (− 18 ± 11 bpm, P = 0.008) and improved diastolic filling time (+ 67 ± 42 ms, P = 0.012) without decreasing cardiac output. At 24 h, Ivabradine improved systolic blood pressure (+ 9 ± 5 mm Hg, P = 0.007), daily urine output (+ 0.7 ± 0.5 L, P = 0.008), oxygen balance (ΔScv02 = + 13 ± 15%, P = 0.010), and NT-pro BNP (− 2270 ± 1912 pg/mL, P = 0.017). Finally, only 2/9 (22%) patients died whereas expected mortality determined from a historical cohort was 78% (P = 0.017).

Conclusion

This pilot study demonstrates the safety and potential benefit of a HR lowering agent in cardiogenic shock.     

Orthopedic Multidimensional Prognostic Index (Ortho-MPI) in the elderly with hip or neck femur fracture: A pilot study

The Orthopedic Multidimensional Prognostic Index (Ortho-MPI) was performed and validated in order to ameliorate the decision-making process as regards the elderly with hip or neck femur fractures. A retrospective study was performed. 95 patients 65 years old and over with a diagnosis of hip or femur fracture were enrolled. A standardized comprehensive orthopedic geriatric assessment was performed. It included information on: depressive symptoms, functional and instrumental activities of daily living, cognitive and nutritional status, laboratory tests, risk of pressure sore, comorbidities and comorbidity. The Ortho-MPI was calculated. After six months their initial assessment, patients were recalled in order to know if they live too or not. The survival condition was associated to the prognostic capacity calculated by the Ortho-MPI. Results showed that higher Ortho-MPI Index value was associated with higher six months-later mortality. In an unvaried analysis model the Ortho-MPI index was associated with death event of the elderly patients enrolled (OR = 1.05; 95% CI, 1.01–1.10; z = 2.27; p = 0.023). This association was also validated by considering different ages between participants (OR = 1.05; 95% CI, 1.004–1.11; z = 2.13; p = 0.033). Furthermore, each specific index considered in the total Ortho-MPI was associated with the death event of the elderly patients. In conclusion it was shown that the Ortho-MPI Index could be used to predict outcome in the elderly with hip or femur fracture.     

Fear of falling (FF): Psychosocial and physical factors among institutionalized older Chinese men in Taiwan

Fear of falling (FF) can have multiple adverse consequences in the elderly. Although there are various fall prevention programs, little is known of FF and its associated characteristics. This study examined FF-associated physical and psychosocial factors in older Chinese men living in a veterans home in southern Taiwan. Subjects with a recent episode of delirium, of bed-ridden or wheelchair-bound status, severe hearing impairment or impaired cognition were excluded. Overall, 371 residents (mean age 82.1 ± 5.11 years, all males) participated. The prevalence of FF was 25.3%. Univariate analysis revealed that subjects in the FF group were older age, having lower education level, poorer sitting and standing balance, poorer activities of daily living (ADL), more depressive symptoms, higher chances of using walking aids, neurologic diseases, and a history of fall within the past 6 months. Logistic regression showed that depressive symptoms (odds ratio = OR = 6.73, 95%CI: 3.03-14.93, p < 0.001), activities of daily living (OR = 2.48, 95%CI: 1.08-5.71, p = 0.033), history of fall in the past 6 months (OR = 2.47, 95%CI: 1.04-5.9, p = 0.041), and neurological diseases (OR = 2.75, 95%CI: 1.15-6.56, p = 0.023) were all independent risk factors for FF.     

Risk stratification of arrhythmogenic right ventricular cardiomyopathy based on signal averaged electrocardiograms

Background

Signal averaged electrocardiogram (SAECG) is a specific and non-invasive tool useful for arrhythmogenic right ventricular cardiomyopathy (ARVC) diagnosis. However, its role in risk stratification of patients with ARVC remains largely undefined.

Methods

Sixty-four patients fulfilling Task Force ARVC criteria (mean age: 47 ± 14 years-old, 56% male, 50% definite ARVC) were enrolled. The baseline demographic, electrocardiographic, structural, and electrophysiological characteristics were collected. Patients with SAECG fulfilling all 3 Task Force criteria (3 + SAECG) were categorized into group 1, and those fulfilled 2 or less criterion were categorized into group 2. The study endpoints were unstable ventricular arrhythmia (VA), device detectable sustained fast VA (cycle lengths < 240 ms) and cardiovascular death.

Results

During a mean follow-up of 21 ± 20 months, 15 primary endpoints including 12 unstable VAs and 3 device-detected fast VAs were met. One patient died of electrical storm, and one patient underwent heart transplantation. The presence of 3 + SAECG predicted malignant events in all patients with definite and non-definite ARVC (p < 0.01, OR = 30.5, 95% CI = 2.5–373.7) and in patients with definite ARVC alone (p = 0.03, OR = 11.1, 95% CI = 1.3–93.9). Patients diagnosed with non-definite ARVC without 3 + SAECG were free from malignant events.

Conclusions

SAECG fulfilling all 3 Task Force criteria was an independent risk predictor of malignant events in ARVC patients. SAECG may play a valuable role in ARVC risk stratification.     

Edentulism risk indicators among Mexican elders 60-year-old and older

The objective of this study was to determine the prevalence of edentulism in Mexican elders aged 60 years and older, and the associated risk indicators. A cross-sectional study was undertaken in 139 elders living in either of two long-term care (LTC) facilities, or attending an adult day center (ADC) in Pachuca, Mexico. A subject was edentulous when natural teeth were completely absent, determined through a clinical examination. Risk indicators were collected using questionnaires. Analyses were performed using binary logistic regression in STATA 9.0. Mean age was 79.0 ± 9.8 years. Many subjects were women (69.1%). The prevalence of edentulism was 36.7%. In multivariate analysis, after adjusting for age and sex, the variables that were inversely associated (p < 0.05) with edentulism were living with a spouse (odds ratio = OR = 0.31), and lacking health insurance (OR = 0.70). Variables associated with higher risk of being edentate were lower educational attainment (OR = 1.61), having received radiation therapy (OR = 4.49), being a smoker (OR = 4.82), and having diabetes (OR = 2.94) or other chronic illnesses (OR = 1.82) (with hypertension approaching significance, p = 0.067). In this sample of Mexican elders, diverse variables were associated with edentulism, in particular smoking and past radiotherapy. Oral health programs within and outside LTC/ADC should take into account risk factors specific to the older population.     

Socioeconomic and environment determinants as predictors of severe malaria in children under 5 years of age admitted in two hospitals in Koudougou district,Burkina Faso: A cross sectional study

Burkina Faso has a high incidence and death rate of severe malaria, especially for children under 5 years of age. Although the malaria elimination program is a high-priority public health project, finding an effective strategy for managing the problem is a major challenge. Understanding the various factors that contribute to the severity of malaria is essential in designing an effective strategy. In this study, parental and environmental factors associated with severe malaria in Burkinabè children were investigated in two hospitals in Koudougou Health District, Burkina Faso. Between July and September 2012, a cross-sectional study was used to test 510 children under 5 years of age (mean age: 23.5 months) admitted with suspected malaria. Each child was screened using a blood smear to identify whether he or she had severe malaria based on the criteria established by the World Health Organization (WHO). When a child was diagnosed with malaria, either severe or not severe, the parents were interviewed by a trained interviewer using a structured questionnaire. A logistic regression was used to identify the determinants of severe malaria and associated deaths. Of the 510 children having malaria, 201 (39.4%) had severe malaria. Most of the patients (54.9%) lived in rural areas. The main factors associated with severe malaria were low education level of the father, low socioeconomic status [odds ratio (OR) = 4.11, 95% confidence interval (CI) = 1.44–11.75], delayed treatment [OR = 4.53, 95% CI = 1.76–11.65], treating children at home as a typical practice when the child has a fever [OR = 3.24, 95% CI = 1.40–7.51], living in rural area [OR = 6.66, 95% CI = 3.36–13.22], and living beside a water gathering pond (OR = 1.67, 95% CI = 1.02–2.74]. Parental and environmental context associated with severe malaria for children under 5 years of age remains a serious public health problem that affects malaria outcomes in resource-limited areas. Promotion of early care is urgently required. Parents should be given information on the risks of not consulting a health facility when children exhibit symptoms of malaria.     

Do physicians with diabetes have differences in dialysis use and survival than other patients with diabetes

Aims

To assess whether the increased knowledge and resources available to physicians led to differences in dialysis and survival rates between physicians and non-physician patients with diabetes.

Methods

All newly diagnosed (1997–2009) type 2 diabetes patients aged ≥35 years from the National Health Insurance Program of Taiwan database were included. After propensity score matching (1:10), we estimated the relative risk of dialysis and death using Cox proportional hazards model adjusted for demographic characteristics and comorbidities.

Results

Physicians with diabetes were more likely to start dialysis than general patients, with a 48% increased hazard risk (HR) (P = 0.006). Physicians with diabetes had significantly lower risk of death (HR: 0.88; P = 0.025). However, those requiring dialysis had a non-significant increased risk of death (HR: 1.19). There was an increased HR for death in older physicians (HR: 1.81; P < 0.001) and those with cancer or catastrophic illness. The HR of dialysis (7.89; P < 0.0001) increased dramatically with increasing Charlson Comorbidity Index scores.

Conclusions

Physicians with DM survived longer than other patients with diabetes, likely benefiting from their professional resources in disease control and prevention. Nonetheless, they displayed no advantage from their medical backgrounds compared with the general patients if they developed end stage renal disease.     

Features of portal hypertension are associated with major adverse events in Fontan patients: The VAST study

Background

Chronic congestive hepatopathy is known to cause hepatic fibrosis and portal hypertension in patients post-Fontan operation for single ventricle palliation. The clinical significance of these findings is not clear. We hypothesized that features of portal hypertension would be significantly related to major adverse events.

Methods

A retrospective review of 73 adult and pediatric post-Fontan patients referred for a liver evaluation from 2001 to 2011 was performed. The relationship between features of portal hypertension (VAST score ≥ 2, 1 point each for Varices, Ascites, Splenomegaly or Thrombocytopenia) and a major adverse event (death, need for transplant, or hepatocellular carcinoma) was examined using logistic regression.

Results

73 post-Fontan patients (30% female, 73% Caucasian, 66% systemic left ventricle (SLV), mean age 24 ± 11 years, mean interval from Fontan 17 ± 6 years) were included in analysis. Features of portal hypertension (VAST score ≥ 2) were present in 26 (36%), and there were 19 major adverse events: death (n = 12), transplant (n = 6), and HCC (n = 1). A significant relationship was found between VAST score ≥ 2 and major adverse events (OR = 9.8, 95% CI [2.9–32.7]). After adjusting for time since Fontan, SLV, age, hemoglobin and type of failure, VAST score ≥ 2 remained significant (OR = 9.1, 95% CI [1.4–57.6]).

Conclusion

Fontan patients with features of portal hypertension have a 9-fold increased risk for a major adverse event. Therapies targeted to manage clinical manifestations of portal hypertension, and early referral to heart transplant may help delay major adverse events. Future prospective studies are needed to confirm these findings.     

Endocarditis infecciosa en 2 hospitales universitarios españoles que difieren en su localización y en la presencia de servicio quirúrgico

Objectives

To assess possible differences in clinical presentation, microbiology, morbidity and mortality of infective endocarditis between two Spanish hospitals, one on the mainland that has cardiac surgery and one in the Canary Islands without this service.

Method

A total of 229 patients consecutively diagnosed of endocarditis between 2005 and 2012, including pediatric population, were studied in the Reina Sofía Hospital (Córdoba, n = 119) and Nuestra Señora de Candelaria Hospital (Tenerife, n = 110). We compared the clinical, microbiological and echocardiographic data and analyzed mortality differences by binary logistic regression analysis.

Results

There were no differences in underlying heart disease, proportion of surgery, or the microbiological profile. The proportion of infections attributable to catheter was higher in the Canary Islands hospital (13.6% vs 3.4%). Mortality was also higher (31.8% vs 18.5%, P = .020), although this difference was no longer significant in the multivariate analysis (OR = 1.85; 95% CI, 0.70-4.87; P = .213). Age (OR = 1.04/year; 95% CI, 1.01-1.07; P = .006), cardiac complications (OR = 5.05; 95% CI, 1.78-14.34; P = .002), persistent sepsis (OR = 4.89; 95% CI, 2.09-11.46; P < .001), and emergent surgery (OR = 4.43, 95% CI, 1.75-11.19; P = .002) were independent predictors of death. Time to surgery, length of stay in the hospital without a surgical service (20 [13-30.5] vs 13 [6-25] days; P = .019) was not associated with outcome.

Conclusions

There are differences in the presentation of endocarditis between two distant hospitals in Spain. The different hospital mortality can not be directly related to the presence of a surgery service.     

Reduced diffusion lung capacity in patients with type 2 diabetes mellitus predicts hospitalization for pneumonia

Among 4164 patients, those with type 2 diabetes mellitus (DM) had lower lung diffusion capacity (DLCO) compared with those without DM (DLCO mean ± SE: 15.7 ± 0.3 vs. 17.0 ± 0.2 mL/min/mm Hg, p < 0.01). Reduced DLCO predicted hospitalization for pneumonia independent of diabetes control, severity and co-morbidities (OR = 2.4, CI 1.08-5.31).