Effects of audit and feedback on professional practice in Geriatric Acute Care Units

PurposeTo evaluate the effects of audit and feedback on service delivery and patient functioning in Austrian Geriatric Acute Care Units.MethodsQuality initiative based on a standardised documentation form (core and optional data set) and a web-based performance feedback with peer comparison in 18 Geriatric Acute Care Units, representing 40% of all Austrian units. Main outcome measures were compliance with desired practice of geriatric care (comprehensive geriatric assessment [CGA], therapeutic consequences), discharge characteristics and mortality.ResultsOverall 22,279 patient records were documented between 2008 and 2010. Active involvement in the web-based feedback system was indicated by a high frequency of data queries per year, 1401, 3148 and 2883 for 2008, 2009 and 2010, respectively. The mean completion rate for CGA tests increased from 73% in 2008 to 78% in 2010 (P < 0.05). For centres with completion of core and optional data (n = 8), the average number of documented therapeutic interventions increased from 4.4 to 5.0 (P < 0.05). Those aspects of CGA focusing on activities of daily living, mobility and cognition prompted the greatest degree of corresponding therapeutic interventions (> 90%). A lower intervention rate was induced by the nutritional assessment (< 20%). Mortality and discharge characteristics such as level of care and percentage of patients living at home after discharge did not change over the time.ConclusionFollowing implementation of a web-based performance feedback with peer comparison in Austrian Geriatric Acute Care Units, an improvement in health care professionals’ compliance with desired practice of geriatric care, but not in patients’ discharge characteristics, was observed.     

Fragilidad y pronóstico de los pacientes mayores con insuficiencia cardiaca

Introduction and objectivesHeart failure (HF) is prevalent in advanced ages. Our objective was to assess the impact of frailty on 1-year mortality in older patients with ambulatory HF.MethodsOur data come from the FRAGIC study (Spanish acronym for “Study of the impact of frailty and other geriatric syndromes on the clinical management and prognosis of elderly outpatients with heart failure”), a multicenter prospective registry conducted in 16 Spanish hospitals including outpatients ≥ 75 years with HF followed up by cardiology services in Spain.ResultsWe included 499 patients with a mean age of 81.4 ± 4.3 years, of whom 193 (38%) were women. A total of 268 (54%) had left ventricular ejection fraction < 40%, and 84.6% was in NYHA II functional class. The FRAIL scale identified 244 (49%) pre-frail and 111 (22%) frail patients. Frail patients were significantly older, were more frequently female (both, P < .001), and had higher comorbidity according to the Charlson index (P = .017) and a higher prevalence of geriatric syndromes (P < .001). During a median follow-up of 371 [361-387] days, 58 patients (11.6%) died. On multivariate analysis (Cox regression model), frailty detected with the FRAIL scale was marginally associated with mortality (HR = 2.35; 95%CI, 0.96-5.71; P = .059), while frailty identified by the visual mobility scale was an independent predictor of mortality (HR = 2.26; 95%CI, 1.16-4.38; P = .015); this association was maintained after adjustment for confounding variables (HR = 2.13; 95%CI, 1.08-4.20; P = .02).ConclusionsIn elderly outpatients with HF, frailty is independently associated with mortality at 1 year of follow-up. It is essential to identify frailty as part of the comprehensive approach to elderly patients with HF.     

Prevalence of anemia among elderly patients in an emergency room setting

PurposeAnemia is highly prevalent in geriatric patients and associated with increased morbidity, functional and cognitive decline. German prevalence data are rare and no treatment guidelines exist for the elderly. Anemia often remains unconsidered in this population. This study evaluates prevalence of anemia among geriatric patients in an emergency room (ER) setting and the performed diagnostic and therapeutic steps.SubjectsData of 1045 elderly patients > 70 years admitted to the ER at our university hospital between January and August 2010 were retrospectively analyzed (384 female and 474 male in-patients, 92 female and 95 male out-patients). Anemia definition: hemoglobin < 12 g/dL (female) and < 13 g/dL (male). Diagnostic and therapeutic steps, medication and hemoglobin (hb) characteristics at transfer from ER to other departments were evaluated.ResultsAmong in-patients anemia was found in 54.2%, among out-patients in 36.4% (P < 0.001). Hb was significantly lower in anemic in-patient men (P = 0.007) compared to anemic out-patient men. No such difference was found among women. Anemic patients’ age did not influence the hb level. There were department specific differences in hb level as well as diagnostics and therapy of anemia. Only 12% of all evaluable anemic in-patients received a non-drug anemia treatment, mostly consisting of transfusions.Discussion/ConclusionMore than 50% of all elderly patients suffered from anemia; less than one fifth received either anti-anemic medication or non-drug treatment; insufficiency of medical care in this study group can be assumed; close intersdisciplinary cooperation with geriatrician in ER is necessary with development of diagnostic and therapeutic guidelines for anemic elderly.     

Serum levels of Apelin-36 are decreased in older hospitalized patients with heart failure

PurposeApelin is an endogenous peptide, it is a potent inotropes, a peripheral vasodilator, involved in fluid homeostasis, balancing the harmful effects of Ang-II-AT1 system. The apelin-APJ axis is down regulated in chronic heart failure (CHF), but the role of apelin has not yet been studied in elderly patients with CHF. The aim of our study is to investigate serum levels of apelin-36 in a group of older subjects with CHF.Subjects/Materials and methodsThe study population consisted of 30 consecutive patients aged 80 ± 7.8 years with CHF. Serum apelin levels were quantified by enzyme immunoassay (ELISA). Results were considered significant if P was < 0.05.ResultsMean values of apelin-36 in CHF patients were 0.47 ± 0.21 ng/mL, and 0.95 ± 0.37 ng/mL in control subjects (P < 0.0001). Patients in IV NYHA class showed lower levels of apelin (0.38 ± 0.16 ng/mL). Direct correlations between apelin levels and ADLs (P = 0.0008, r = 0.61), and IADLs (P = 0.008, r = 0.50) were observed.Discussion and conclusionsThis study confirms that apelin levels are decreased in patients with CHF, also in the elderly and frail; since apelin represents a potential, promising novel therapeutic target for patients with CHF, geriatric patients should be considered for future clinical trials.     

The impact of transoesophageal echocardiography in elderly patients with infective endocarditis

BackgroundInfective endocarditis (IE) increasingly involves older patients. Geriatric status may influence diagnostic and therapeutic decisions.AimTo describe transoesophageal echocardiography (TEE) use in elderly IE patients, and its impact on therapeutic management and mortality.MethodsA multicentre prospective observational study (ELDERL-IE) included 120 patients aged ≥75 years with definite or possible IE: mean age 83.1± 5.0; range 75–101 years; 56 females (46.7%). Patients had an initial comprehensive geriatric assessment, and 3-month and 1-year follow-up. Comparisons were made between patients who did or did not undergo TEE.ResultsTransthoracic echocardiography revealed IE-related abnormalities in 85 patients (70.8%). Only 77 patients (64.2%) had TEE. Patients without TEE were older (85.4 ± 6.0 vs. 81.9 ± 3.9 years; P = 0.0011), had more comorbidities (Cumulative Illness Rating Scale-Geriatric score 17.9 ± 7.8 vs. 12.8 ± 6.7; P = 0.0005), more often had no history of valvular disease (60.5% vs. 37.7%; P = 0.0363), had a trend toward a higher Staphylococcus aureus infection rate (34.9% vs. 22.1%; P = 0.13) and less often an abscess (4.7% vs. 22.1%; P = 0.0122). Regarding the comprehensive geriatric assessment, patients without TEE had poorer functional, nutritional and cognitive statuses. Surgery was performed in 19 (15.8%) patients, all with TEE, was theoretically indicated but not performed in 15 (19.5%) patients with and 6 (14.0%) without TEE, and was not indicated in 43 (55.8%) patients with and 37 (86.0%) without TEE (P = 0.0006). Mortality was significantly higher in patients without TEE.ConclusionsDespite similar IE features, surgical indication was less frequently recognized in patients without TEE, who less often had surgery and had a poorer prognosis. Cardiac lesions might have been underdiagnosed in the absence of TEE, hampering optimal therapeutic management. Advice of geriatricians should help cardiologists to better use TEE in elderly patients with suspected IE.     

Les protéines purifiées à partir de sardines améliorent les chiffres tensionnels,l’équilibre glycémique,les voies métaboliques anti-athérogènes et la capacité anti-oxydante,chez le rat obèse

Aim of the studyThe effects of sardine by-products (SBy-P) and fillet proteins (SF-P) were compared to casein (Cas) ; these effects were assessed on blood pressure, glycemic control, reverse cholesterol transport, lipid peroxidation and total antioxidant capacity in obese rats.Materials and methodsEighteen male Wistar rats were subjected for three months, to a high-fat diet. The obese rats were divided into three groups and consumed the same high-fat diet for 28 days after addition of either, 20% SBy-P, SF-P or Cas.ResultsThe sardine proteins (SBy-P and SF-P) compared respectively to Cas, reduced diastolic (−14%, −11% P < 0.05) and systolic pressures (−12%, −8% P < 0.05), blood glucose (−24%, −21% P < 0.05), glycated hemoglobin (−28%, −21% P < 0.05), insulinemia (−29%, −18% P < 0.05) and HOMA-IR index (−29%, −18% P < 0.05). They improve the reverse cholesterol transport by increasing the lecithin: cholesterol acyltransferase (LCAT) activity (+43%, +30% P < 0.05) and high-density lipoproteins in cholesterol esters (+108%, +88% P < 0.05), and decreasing the atherogenicity ratios and membrane fluidity (P < 0.05). Furthermore, SBy-P and SF-P induced a reduction of reactive thiobarbituric acid substances concentrations in heart (−45%, −25% P < 0.05), aorta (−62%, −41% P < 0.05), liver (−40%, −21% P < 0.05) and adipose tissue (−50%, −37% P < 0.05) with an improvement in antioxidant capacity.ConclusionSardine proteins, in particular those extracted from by-products, because of their hypotensive, hypoglycemic, anti-atherogenic and antioxidant properties, may have protective effects against the cardiovascular risk associated with obesity.     

Centrally active prescribing for nursing home residents - how are we doing?

IntroductionOlder patients in nursing homes are more likely to be prescribed multiple drugs than other age groups as multimorbidity is the norm. This clinical study reviewed all prescribed centrally active medications for residents in a nursing home in Dundee. Subsequent analysis was carried out to examine whether particular patient criteria are associated with an exposure to centrally acting drugs and to examine the adequacy of analgesia for care home residents.MethodsThe study was carried out in a Dundee nursing home with two different units with varying admission criteria. The research team reviewed patient records establishing background patient characteristics and medical diagnoses where psychoactive prescribing may be appropriate. In addition, information on specific prescribed medications, patient pain scores (PAINAD system), quantified cognition (6CIT score) was gathered. The non-parametric Mann Whitney U test (P < 0.05) was used to compare exposure to CNS active medications between nursing home floors.ResultsPatients with dementia in nursing homes are particularly likely to have bodily pain, insomnia and unipolar depression. Patients with more severe dementia were statistically more likely to be exposed to CNS active medications (P-value = 0.01). Importantly, despite being exposed to significant levels of psychoactive prescribing this patient group may be undertreated for chronic pain.ConclusionCentrally active prescribing in the community for geriatric patients remains high and may be associated with patient risk. Furthermore, despite this patients may be undertreated for pain syndromes.     

Présentation clinique et performance de la bandelette urinaire pour le diagnostic d’infection urinaire en population gériatrique

BackgroundUrinary tract infections (UTI) are the second cause of community-acquired bacterial infections in the elderly. Distinguishing symptomatic UTI from asymptomatic bacteriuria is problematic, as older adults are less likely to present with localized urinary symptoms. We evaluated characteristics of patients presenting UTI among elderly with sepsis. Moreover, we aimed to evaluate the sensibility and specificity of urine dipstick tests in the diagnosis of UTI in geriatric population.Patients and methodWe led a prospective, monocentric, observational study between April 2017 and January 2018. We included patients hospitalized in geriatric wards, who were prescribed urine culture for UTI symptoms or/and infection without primary sites for which a urine culture was prescribed. Dipstick urinalyses were performed for all patients.Clinical and biological characteristics of all patients were compared according to the final diagnosis of UTI. Moreover, results of dipstick tests were evaluated for the diagnosis of UTI in this population.ResultsAmong 165 patients, 67 (40.6 %) had a UTI and 98 (59.4 %) had another diagnosis. These two groups were comparable for age and daily-living activities. In the UTI group, the proportion of women was higher than in the other group (P < 0.05), and mean MMSE score was lower (P < 0.05).Positive urine dipstick test for leukocytes and/or nitrites had high sensitivity (92 %), but low specificity (50 %). Negative predictive value of this test was high (91 %).ConclusionFor suspicion of UTI among elderly, few criteria are specific. Negative dipstick tests can suggest an absence of UTI due to its high negative predictive value.     

A brief psychological intervention to improve adherence in type 2 diabetes

ObjectiveDiabetes perceptions, acceptance and treatment motivation are changeable factors of adherence. This study aimed to test the effects of brief psychological interventions based on diabetes threat and mastery perceptions in terms of adherence, acceptance and motivation. Physicians may find such interventions useful during a 15-minute consultation with diabetes patients.Research design and methodsThis randomized controlled study included 80 patients with type 2 diabetes, recruited from the hospital diabetes department, who were randomly assigned to four intervention groups based on autobiographical recall. Those in the two intervention groups were asked to recall diabetic events based on mastery and threat perceptions, respectively, whereas those in the two control groups recalled non-diabetic events based on positive and negative emotions, respectively. Following this, all participants completed validated self-questionnaires assessing diabetes perceptions, acceptance, treatment motivation and adherence.ResultsPatients in the threat group reported less adherence (P < 0.01) and less avoidance (P < 0.05), and perceived diabetes as less threatening (P < 0.05) than those in the mastery group. Similar results were obtained when the threat group was compared with its matched negative-emotion control group (P < 0.05, P < 0.05 and P = 0.087, respectively). Patients in the mastery group reported feeling a stronger sense of mastery (P < 0.05) than those in their positive-emotion control group and greater treatment acceptance than those in the threat group (P < 0.01).ConclusionContrary to conventional medical belief, discussing threatening personal events with patients can yield positive results. Health professionals should take threat and mastery perceptions of diabetes into account during regular consultations with a view to improving treatment acceptance and adherence. With this brief intervention of type 2 diabetes patients, it was also more effective to alleviate their emotional difficulties than to enhance their perception of mastery.     

Out of sight,out of mind? Does terminating the physical presence of a geriatric consultant in the community clinic reduce the implementation rate for geriatric recommendations

AimTo assess the effect of moving the geriatric consultation from the primary care clinic to another setting, on the rate of implementation of geriatric recommendations by family physicians.MethodsA retrospective review of the computerized medical records of elderly patients in four primary care clinics. The rate of implementation of geriatric recommendations was compared between clinics in which a geriatric consultant was physically present (control clinics) and a clinic where the consultation took place elsewhere (study clinic). In addition, the results of the present study were compared to a previous study in which the geriatric consultation was carried out in the study clinic and the family doctor was an active participant.Results127 computerized files were reviewed in the study clinic and 133 in the control clinics. The mean age of the patients was 81.1 ± 6.3 years and 63.1% were women. The overall implementation of geriatric recommendations by family doctors in the study clinic was 55.9%, a statistically significant decrease compared to the previous study where the rate was 73.9% (p < 0.0001). In contrast, there was no change in the implementation rate in the control clinics at 65.0% in the present study and 59.9% in the previous one (p = 0.205).ConclusionsDirect, person-to-person contact between the geriatric consultant and the family doctor has a beneficial effect on the implementation of geriatric recommendations. This should be considered by healthcare policy makers when planning geriatric services in the community.     

Prognostic Utility of Anemia and Pro-B-Type Natriuretic Peptide in Patients With Nonischemic Dilated Cardiomyopathy and Normal Renal Function

BackgroundIdiopathic dilated cardiomyopathy frequently coexists with anemia and high plasma NT proBNP levels. However, the prognostic impact of these features on the disease course is uncertain, especially in patients with normal renal function.MethodsForty-seven patients with idiopathic dilated cardiomyopathy with sinus rhythm and normal renal function were prospectively followed for a mean 25 ± 18 months period. Clinical end points were death (sudden cardiac death and deaths because of worsening heart failure) and cardiac transplantation. Prognostic impact of NT proBNP levels, anemia, echocardiographic and clinical parameters on the clinical end points was evaluated with Kaplan-Meier survival analysis. Cut-off values of hemoglobin and plasma NT proBNP levels for predicting end points were determined by receiver operating curve analysis.ResultsTwenty-eight patients (59.6%) suffered clinical end points. The patients who suffered clinical end points were anemic (P = 0.002), had lower systolic (P < 0.003) and diastolic (P < 0.0001) blood pressures, and higher NYHA functional classes (P = 0.005), lower left ventricle ejection fractions (P = 0.003), higher E/A ratios (P = 0.001), shorter E-wave deceleration times (P = 0.001), isovolumetric relaxation times (P = 0.05) and pulmonary acceleration times (P = 0.004), and higher plasma NT proBNP levels (P < 0.0001). Anemic patients had more clinical end points (P = 0.002). In univariate analysis the prognostic predictors of life expectancy were log NT proBNP, anemia, NYHA functional class, systolic blood pressure, left ventricle ejection fraction, and E-wave deceleration time. However, multivariate analysis revealed only plasma NT proBNP as independent predictor of clinical end points.ConclusionTracking plasma NT proBNP levels is a useful strategy during routine follow-ups of patients with nonischemic dilated cardiomyopathy. Its predictive value for prognosis needs more evaluation in larger controlled studies. In addition, the importance of anemia in those patients needs more study.     

Living wills and end-of-life care of older people suffering from cardiovascular diseases: A ten-year follow-up

BackgroundLiving will (LW) documents have been suggested to act in patients’ best interests in end-of-life care. It is unclear, however, whether the LWs influence medical decisions when death is impending.AimTo explore, whether a LW among the community-dwelling older people has an influence on intensity of end-of-life treatment, place of death, or length of the dying process.DesignA 10-year follow-up; data concerning place and cause of death, event history, intensity of care, decision-making process, and length of the dying process were collected from the death certificates.Setting/ParticipantsIn a community-based longitudinal cardiovascular prevention trial (DEBATE) in Helsinki, home-dwelling older people with an atherosclerotic disease (n = 378, mean age 80.2 years) were questioned about the pre-existence of a written LW at baseline (n = 44) in 2000. In 2010, all death certificates (n = 207) were analysed, comparing people with a LW (n = 30) at baseline with those without (n = 177).ResultsOf the deceased, 77% died in hospital. Intensity of end-of-life treatment or cause of death did not differ between the groups. However, dying at home was more common among persons with a LW at baseline (16.7% vs. 5.6%, P = 0.031), and length of the dying process was shorter in this group (< 1 week in 50.0% vs. 27.1%, P = 0.013).ConclusionsLength of the dying process was often shorter and home death more common among those with a LW at the beginning of the follow-up. More insight into the dying process is required to ensure that the decision-making process better accommodates the preferences of older people.     

Protection effect of [Gly14]-Humanin from apoptosis induced by high glucose in human umbilical vein endothelial cells

AimsHumanin (HN) is known for its anti-apoptotic functions in neuronal cells. In this study, we sought to investigate the protective effect of [Gly14]-Humanin (HNG) in high glucose (HG)-induced apoptosis of human umbilical vein endothelial cells (HUVECs).Methods3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay was used to examine cell viability, DNA chromatin morphology was assessed using Hoechst 33342 staining, and the generation of intracellular reactive oxygen species (ROS) was assessed using the fluorescent probe dichlorofluorescein diacetate (DCFH-DA). The expression of poly ADP-ribose polymerase (PARP), the pro-apoptotic protein bax and the anti-apoptotic protein bcl-2 were examined using western blot analysis. The mRNA level of bax and bcl-2 were detected by quantitative Real-Time PCR.ResultsCompared with treatment with HG 72 h, pretreatment with HNG for 3 h significantly increased cell viability (P < 0.001), reduced nuclear fluorescence of HUVECs (P < 0.05), the levels of cleaved PARP (P < 0.05), ROS formation (P < 0.05) and the ratio of bax/bcl-2 (P < 0.05) compared with treatment with HG for 72 h. Quantitative Real-Time PCR showed that mRNA level of bax reduced (P < 0.05) and mRNA level of bcl-2 increased (P < 0.05) after pretreatment with HNG.ConclusionsOur results imply that HNG can protect HUVECs from apoptosis induced by HG through the bax/bcl-2 pathway.     

Cardiothoracic Ratio,Inflammation, Malnutrition,and Mortality in Diabetes Patients on Maintenance Hemodialysis

BackgroundThis study investigates diabetic patients on maintenance hemodialysis (HD), and examines whether cardiothoracic ratio (CTR), malnutrition, and inflammation are closely interrelated, and whether CTR predicts short-term mortality in this population.MethodsA 2-year longitudinal study that enrolls 179 patients—73 without cardiomegaly (CTR < 50%), 81 with mild cardiomegaly (CTR 50%–60%), and 25 with moderate-to-severe cardiomegaly (CTR > 60%).ResultsSpearman analysis established that CTR was positively correlated with age (P < 0.001) and high sensitivity C reactive protein (HsCRP) (P < 0.05), but negatively correlated with albumin (P < 0.05) and creatinine (P < 0.001). Multivariate logistic analyses identified age (P = 0.0027), creatinine (P = 0.0484), intact-PTH (P = 0.0197) and HsCRP (P = 0.0247) were independent determinants of cardiomegaly. After 2 years, 31 of 179 (17.32%) patients died including 9 of 25 (36%) with CTR > 60%, 14 of 81 (17.28%) with CTR 50%–60%, and 8 of 73 (10.96%) with CTR < 50%. The primary causes of death were infection (61.29%) and cardiovascular disease (CVD) (32.26%). Cox multivariable regression analysis revealed CTR > 50% was the only independent variable for the development of all-cause and infection-cause mortality in 2 years. Kaplan-Meier analysis confirmed that patients with CTR > 60% suffered higher cumulative mortality than patients with CTR < 50% (P = 0.0003).ConclusionsCTR does not only correlate with inflammation and nutritional status in diabetic patients on maintenance HD, but also predict the all-cause and infection-cause 2-year mortality.     

Evaluation of visfatin in patients with systemic lupus erythematosus: Correlation with disease activity and lupus nephritis

IntroductionRenal involvement affects about 50% of SLE patients accounting for significant morbidity and mortality in these patients. The adipokine “visfatin” acting as a growth factor for B-lymphocyte-precursors, exerts several proinflammatory functions. It was demonstrated as a marker of endothelial dysfunction (ED) in chronic kidney disease (CKD) thus could be a factor linking inflammation in SLE and kidney disease.Aim of the workTo assess serum visfatin level in SLE patients and its correlation to disease activity and lupus nephritis (LN) in these patients.Patients and methodsSerum level of visfatin using enzyme-linked immunosorbent assay (ELISA), chemical and immunological markers of SLE and LN were measured in 40 SLE patients and 40 age and sex matched healthy controls. Disease activity and renal involvement were assessed using SLE Disease Activity Index (SLEDAI) and Renal SLEDAI respectively further dividing patients into active versus inactive and LN versus non-LN respectively. Renal biopsies were taken from LN subgroup and were classified according to the modified WHO classification.ResultsA significantly higher serum visfatin level was found on comparing SLE patients (mean 109 ± 180 ng/ml, median18) with controls (mean 9.4 ± 11 ng/ml, median2.5) with statistically highly significant difference (z = 5.2, P < 0.001). Also there was a statistically significant difference as regards serum visfatin level between active SLE patients (mean 173 ± 111 ng/ml, median 14) and inactive patients (mean 139 ± 88 ng/ml, median 5) (z = 2.1, P < 0.05) as well as between patients with LN (mean 226 ± 180 ng/ml, median18) and patients with no LN (mean 101 ± 140 ng/ml, median 8(2-229)) (z = 2.1, P < 0.05). Visfatin had a highly significant positive correlation with disease duration (r = 0.48, P < 0.001), SLEDAI (r = 0.62, P < 0.001) as well as ESR, CRP and, renal score (r = 0.45, 0.35, and 0.65, respectively) while inverse correlation with estimated GFR (r = ?0.614) and C3 and C4 titre (r = ?0.26, r = ?0.35, respectively) was recorded. Visfatin showed high sensitivity in detecting active SLE and LN 83% and 85%, respectively.ConclusionSerum visfatin is strongly associated with LN in SLE patients and is a promising biomarker for prediction of renal involvement in these patients. It reflects SLE activity specially LN activity namely renal score and GFR decline. Further prospective studies are required to confirm visfatin as a destructive mediator of predictive and prognostic value in active lupus nephritis.     

Assessment of response to sorafenib in advanced hepatocellular carcinoma using perfusion computed tomography: Results of a pilot study

AimsThis prospective pilot study investigated the feasibility of perfusion computed tomography parameters as surrogate markers of angiogenesis and early response following sorafenib administration in patients with advanced hepatocellular carcinoma.MethodsTen patients were evaluated with perfusion computed tomography before starting sorafenib and after 3 months. Blood flow, blood volume, mean transit time, hepatic arterial fraction, and permeability surface-product were compared in tumour lesions and in hepatic parenchyma at baseline and at follow-up. Correlation between these parameters and changes in alpha-fetoprotein levels was calculated.ResultsAt baseline, blood volume, blood flow, hepatic arterial fraction and permeability surface values were higher in lesions compared to those in hepatic parenchyma, while mean transit time was lower (p < 0.05). After sorafenib treatment, only mean transit time was significantly increased versus baseline (p < 0.05). At follow-up, plasma alpha-fetoprotein levels decreased in all patients. At follow-up, an inverse correlation was observed between baseline mean transit time and changes in alpha-fetoprotein (r = ?0.6685, p = 0.0125), as well as a correlation between baseline blood flow and alpha-fetoprotein (r = 0.6476, p = 0.0167).ConclusionThis pilot study suggests that after sorafenib treatment an increase in mean transit time observed in tumour lesions is inversely correlated with alpha-fetoprotein reductions after therapy. Mean transit time may represent a possible marker of response irrespectively of alpha-fetoprotein values.     

Diet,body composition,and physical fitness influences on IGF-I bioactivity in women

ObjectiveInsulin-like growth factor I (IGF-I) is a metabolic-regulatory hormone that mediates a variety of physiologic functions. Body composition, fitness status and intake of certain micro- and macronutrients are associated with circulating concentrations of immunoreactive IGF-I. The influence of these factors on IGF-I bioactivity; however, is undetermined. We assessed the relationships between IGF-I bioactivity and lifestyle factors purportedly associated with IGF-I immunoreactivity.DesignIn a cross sectional study, fasted blood samples were obtained from 44 lightly active, college-age (20 ± 2 yrs) women. IGF-I bioactivity was estimated by an assay which determines the ability of serum IGFs to phosphorylate IGF-I receptors in cultured cells; free and total IGF-I were measured by immunoassay. Estradiol and progesterone were measured by immunoassay. Body mass index was calculated from measured height and weight, bone mineral density and body fat percentage measured by dual energy X-ray absorptiometry, and peak oxygen consumption (VO_2peak) determined during a graded treadmill protocol. A food frequency questionnaire measured habitual and a 5-day food record assessed short-term micro- and macronutrient intakes. Associations between bioactive, free and total IGF-I with body composition, sex hormones, VO_2peak, and dietary intake were assessed using univariate and multiple linear regression analyses.ResultsAssociations between bioactive IGF-I with age (r = ?0.36, P < 0.05), body fat percentage (r = ?0.32, P < 0.05), estradiol (r = 0.31, P < 0.05) and progesterone (r = 0.33, P < 0.05) concentrations, habitual alcohol (r = ?0.38, P < 0.05) and selenium intakes (r = 0.41, P < 0.01), free IGF-I with age (r = ?0.34, P < 0.05), estradiol (r = 0.48, P < 0.01) and progesterone (r = 0.52, P < 0.001) concentrations, habitual alcohol (r = ?0.33, P < 0.05) and isoflavone intakes (r = 0.30, P < 0.05) and total IGF-I with age (r = ?0.27, P < 0.05) and habitual alcohol intake (r = ?0.33, P < 0.05) were observed. Habitual alcohol intake was a negative predictor of bioactive, free and total IGF-I in multivariate models.ConclusionOf the lifestyle factors measured, the most robust relationship observed was a negative association between habitual alcohol intake and all measures of IGF-I. This finding suggests that alcohol intake may blunt the physiologic actions of the IGF-I axis.     

Chronic kidney disease predicts poor prognosis in patients with stable premature coronary artery disease

ObjectiveThis study was performed to determine the prevalence of chronic kidney disease (CKD) as well as its association with mid-term prognosis in patients with stable premature coronary artery disease (CAD) in a Chinese population.MethodsFive hundred and twelve patients from Jiangsu Province, China with stable, premature CAD were enrolled using an estimated glomerular filtration rate (eGFR) to determine the presence of CKD. The patients were then monitored over a two-year follow up during which major adverse cardiac events (MACEs) were recorded and analyzed.ResultsOne hundred and eighty-three patients (35.74%) were determined to have CKD. Having CKD was associated with a higher ratio of type 2 diabetes mellitus, multi-vessel disease, higher levels of fasting blood sugar and lower levels of left ventricular ejection fraction (all P < 0.05). Patients with CKD had significantly higher incidences of composite MACEs than the non-CKD group at the end of the two- (45.35% vs 30.72%, P = 0.001) but not one-year follow up (30.64% vs 25.32%, P = 0.209). Furthermore, as eGFR decreased, more MACEs occurred (all P < 0.05). Multivariate analysis confirmed that both CKD (P < 0.001) and multi-vessel disease (P < 0.001) are independent risk factors for MACEs.ConclusionChinese patients diagnosed with stable, premature CAD and CKD have more risk factors and worse two-year outcomes than those with only CAD.     

Cholesterol metabolism in pediatric short bowel syndrome after weaning off parenteral nutrition

BackgroundSmall intestine essentially regulates cholesterol homeostasis.AimsTo evaluate cholesterol metabolism in short bowel syndrome (SBS).MethodsCholesterol precursors (e.g., cholestenol, desmosterol and lathosterol) and plant sterols (campesterol and sitosterol), respective markers of cholesterol synthesis and absorption, were determined in SBS patients (n = 12) an average of 31 months after weaning off parenteral nutrition and in age-matched controls (n = 80).ResultsAmong patients, serum cholesterol precursor sterol to cholesterol ratios were 2–10 times higher (P < 0.0001 for each). Those without any remaining ileum had 1.2–2.8 times higher precursor sterol to cholesterol ratios than those with an ileal remnant (P < 0.05 for each). Serum cholesterol concentration, campesterol/cholesterol and campesterol/sitosterol were 34–39% lower (P < 0.05 for each) in relation to controls. Bile acid absorption was markedly impaired (2.4 (0.2–3.2)%). Plant sterol ratios reflected the absolute length of remaining jejunum (r = 0.625–0.663), and precursor sterol ratios inversely that of ileum (r = −0.589 to 0.750, P < 0.05 for all).ConclusionAfter weaning off parenteral nutrition, patients with pediatric onset SBS continue to have marked intestinal malabsorption of bile acids and moderate cholesterol malabsorption resulting in decreased serum cholesterol despite a marked compensatory increase in cholesterol synthesis.