Assessing cachexia in older patients: Different definitions – But which one is the most practical for clinical routine?

ObjectivePatients with chronic inflammatory diseases and malignant tumors have an increased risk of cachexia. No consistent definition exists to rapidly identify cachexia in older patients with and without cancer.MethodsOne-hundred patients (53% male) aged 70 + years were included in the study by a university hospital. In addition to the detection of malnutrition and determination of body composition by bioelectrical impedance analysis, cachexia was assessed according to the well-established definitions of Evans (weight loss ≥ 5% within the last 12 months plus additional clinical parameters), Fearon (weight loss > 5% in 6 months) and Bozzetti (weight loss ≥ 10% of habitual weight). After a follow-up of 3.5 years, the mortality rate was recorded.ResultsThirty-three patients had a malignant tumor disease. The patients with a non-malignant underlying disease did not differ in their mental state, physical condition and state of health compared to patients with cancer. A higher percentage of patients with underlying malignancy had cachexia. There were significant differences in the body composition between the patients with or without cachexia. Cachectic patients exhibited a significantly lower skeletal muscle mass and fat mass. The risk of death was increased in cachectic patients of all three cachexia definitions.ConclusionFor clinical daily routine, the assessments by a weight loss according to Fearon and Bozzetti are suggested to be practicable methods to detect cachexia in older patients with and without cancer.     

Is routine screening for urinary tract infection in rehabilitation day-hospital elderly patients necessary?

It is not known whether all rehabilitation day-hospital patients need to be assessed for urinary tract infection (UTI). The aims of this study were to identify patients at high risk to develop UTI and to determine whether there was an association between the amount of post-void residual urine (PVR) and UTI. We surveyed 211 consecutive patients admitted to the day-hospital unit of a geriatric rehabilitation center between June 1998 and February 1999. The main diagnoses were stroke, orthopedic surgeries and deconditioning. Urine samples for general analysis and bacteriology were collected from each patient upon admission. PVR was measured using portable ultrasound. Telephone interviews were conducted with 141 patients, 3-11 months after the initial screening. The prevalence of UTI at admission was higher in women (P=0.007), and patients with decreased functional level (P=0.001). The incidence rate correlated with the functional level but not with gender or main diagnosis. The relative risk of dependent patients to develop UTI was 7.5 times higher than in independent patients. Significant amounts of PVR were equal in males and females. The relative risk of individuals with significant amounts of PVR to develop UTI was 1.63 times greater then those with negligible and moderate amounts of PVR. Gender, degree of functional level and main diagnosis had no effect on the relationship between PVR and UTI. We conclude that low functional level and significant amounts of PVR are risk factors for prevalence and incidence of UTI in elderly patients in a rehabilitation day-hospital. There is no need for routine urine analysis in every elderly patient admitted to rehabilitation day-hospitals, however, PVR measurements by portable ultrasound are valuable.     

The management of uncomplicated adult gonococcal infection: should test of cure still be routine in patients attending genitourinary medicine clinics?

In this retrospective study of the outcome of treatment of 245 patients (87 females and 158 males) with a diagnosis of Neisseria gonorrhoeae infection seen between 1996 and 2002, 81% (95% confidence interval (CI) 74%-86.8%) of the males and 88.5% (95% CI 79.9%-94.3%) of the females attended for a test of cure. At initial presentation, 93% (95% CI 87.9%-96.5%) and 94.3% (95% CI 89.5%-97.4%) of males respectively, had symptoms and signs of gonococcal infection compared with 48.3% (95% CI 37.4%-59.2%) and 44.8% (95% CI 34.1%-55.9%) of females, and this difference was statistically significant (P = 0.005). Initial diagnosis at first visit was made by Gram-stained smear in 88.6% (95% CI 82.6%-93.1%) of males and 32.2% (95% CI 22.6%-43.1%) of females, a statistically significant difference P = 0.001. There were 12 (4.9%) cases of reinfection that rebooked to attend after failing to attend for their test of cure in two females and 10 males. There were two (0.8%) treatment failures amongst the 245 episodes in two males who still had symptoms when they returned for their test of cure. One male had a ciprofloxacin-resistant strain (CRNG) acquired locally and the other one had a betalactamase-producing CRNG/penicillinase-producing N. gonorrhoeae (PPNG) isolate acquired abroad in South America. These patients would have sought to return, as they still had signs and symptoms of gonococcal infection, and they would have been recalled following receipt of the antimicrobial susceptibility report. Post-gonococcal urethritis occurred in 36.3% (95% CI 27.8%-45.4%) of the males who attended for their test of cure, 74.8% (95% CI 67.2%-81.5%) received anti-chlamydial therapy with their standard treatment. In men who received anti-chlamydial therapy the odds ratio of having post-gonococcal urethritis was 0.42 (95% CI 0.17-1.06), P = 0.04. Co-infection with Chlamydia trachomatis was more likely to occur amongst females (43.9%), odds ratio 3.97 (95% CI 2.07-7.67), P < 0.001 than males (16.5%). We have now discontinued routine attendance for a test of cure and encourage our patients to telephone for their results with recall only of patients whose antimicrobial susceptibility indicate inappropriate first line therapy or who are still symptomatic.     

Colorectal cancer surveillance in patients with inflammatory bowel disease: What is new?

Several studies assessing the incidence of colorectal cancer (CRC) in inflammatory bowel disease (IBD) patients have found an increased risk globally estimated to be 2 to 5 times higher than for the general population of the same age group. The real magnitude of this risk, however, is still open to debate. Research is currently being carried out on several risk and protective factors for CRC that have recently been identified in IBD patients. A deeper understanding of these factors could help stratify patient risk and aid specialists in choosing which surveillance program is most efficient. There are several guidelines for choosing the correct surveillance program for IBD patients; many present common characteristics with various distinctions. Current recommendations are far from perfect and have important limitations such as the fact that their efficiency has not been demonstrated through randomized controlled trials, the limited number of biopsies performed in daily endoscopic practice, and the difficulty in establishing the correct time to begin a given surveillance program and maintain a schedule of surveillance. That being said, new endoscopic technologies should help by replacing random biopsy protocols with targeted biopsies in IBD patients, thereby improving the efficiency of surveillance programs.However, further studies are needed to evaluate the cost-effectiveness of introducing these techniques into daily endoscopic practice.     

Is hepatitis C more aggressive in renal transplant patients than in patients with end-stage renal disease?

BACKGROUND: The eventual impact of immunosuppression on the natural history of hepatitis C virus (HCV) infection in patients with end-stage renal disease (ESRD) is still unknown because of the lack of comparative data for HCV-infected patients with ESRD and renal transplant patients. The aim of this study was to compare the biochemical and histological characteristics of chronic HCV infection in renal transplants patients and ESRD patients undergoing hemodialysis. METHODS: Thirty-eight renal transplant patients and 38 ESRD patients undergoing hemodialysis who were chronically infected with HCV and were matched for gender, age at infection, and estimated time of infection were included in the study. The groups were compared regarding laboratory and histological variables. RESULTS: Renal transplant patients showed similar alanine aminotransferase and higher gamma-glutamyltransferase levels (P = 0.05) when compared with ESRD patients. Comparative analysis of histological variables revealed a higher proportion of cases with septal fibrosis (P = 0.04) and confluent necrosis (P = 0.01) among transplant-recipient patients. No difference between groups was observed regarding the intensity of portal and periportal inflammatory infiltrates. Steatosis was more prevalent among transplant-recipient patients (P < 0.001). There was no difference between groups regarding the prevalence of lymphoid aggregates or bile duct injury. CONCLUSION: Renal transplant patients had a larger proportion of cases with septal fibrosis and confluent necrosis than did ESRD patients, suggesting that renal transplantation might modify the natural history of hepatitis C in ESRD patients, leading to a more aggressive liver disease.