Does the mini nutritional assessment predict hospitalization outcomes in older people?

BACKGROUND: the Mini Nutritional Assessment is a validated clinical tool for the assessment of nutritional status in older people. Moderate to severe malnutrition is common in elderly patients in hospital and is associated with a poor outcome. OBJECTIVES: to determine whether the Mini Nutritional Assessment can predict the outcome of hospital stay in older individuals. SETTING: a tertiary-care geriatric hospital. METHODS: we evaluated nutritional status using the Mini Nutritional Assessment in 1319 patients (mean age 84.2, 70% women) admitted between February 1996 and January 1998; 1145 complete assessments were available for analysis. The assessment was carried out on admission and studied in relation to length of stay and in-hospital mortality for all patients, and discharge to a nursing home for those living at home before admission. RESULTS: Mini Nutritional Assessment scores averaged 19.9+/-3.8 (mean+/-SD) with a range of 8.0-27.5, and a median of 20.5. A score below 17, corresponding to malnutrition, was associated with an almost threefold increase in mortality and in the rate of discharge to a nursing home; this contrasted with a score above 24, which indicates satisfactory nutritional status (11.3% vs 3.7%; P<0.01 and 20.3% vs 7.7%; P<0.001, respectively). Length of stay was longer in the low scoring group (42.0 days vs 30.5 days; P<0.0002). CONCLUSION: Poor nutritional status as measured by the Mini Nutritional Assessment was associated with increased in-hospital mortality, a higher rate of discharge to nursing homes and a longer length of stay.     

Slowing down as an early warning signal for abrupt climate change

In the Earth's history, periods of relatively stable climate have often been interrupted by sharp transitions to a contrasting state. One explanation for such events of abrupt change is that they happened when the earth system reached a critical tipping point. However, this remains hard to prove for events in the remote past, and it is even more difficult to predict if and when we might reach a tipping point for abrupt climate change in the future. Here, we analyze eight ancient abrupt climate shifts and show that they were all preceded by a characteristic slowing down of the fluctuations starting well before the actual shift. Such slowing down, measured as increased autocorrelation, can be mathematically shown to be a hallmark of tipping points. Therefore, our results imply independent empirical evidence for the idea that past abrupt shifts were associated with the passing of critical thresholds. Because the mechanism causing slowing down is fundamentally inherent to tipping points, it follows that our way to detect slowing down might be used as a universal early warning signal for upcoming catastrophic change. Because tipping points in ecosystems and other complex systems are notoriously hard to predict in other ways, this is a promising perspective.     

Palliative care for the geriatric patient in Europe

Background

Knowledge about the quality of end-of-life care in the elderly patient in Europe is fragmented. The European Union Geriatric Medicine Society (EUGMS) Geriatric Palliative Medicine (GPM) Interest Group set as one of its goals to better characterize geriatric palliative care in Europe.

Objective

The goal of the current study was to map the existing palliative care structures for geriatric patients, the available policies, legislation, and associations in geriatric palliative medicine in different countries of Europe.

Methods

A questionnaire was sent to Geriatric and Palliative Medicine Societies of European countries through contact persons. The areas of interest were (1) availability of services for the management of geriatric patients by using vignette patients (advanced cancer, severe cardiac disease, and severe dementia), (2) policies, legislation of palliative care, and (3) associations involved in geriatric palliative medicine.

Results

Out of 21 countries contacted, 19 participated. Palliative care units and home care palliative consultation teams are available in most countries. In contrast, palliative care in long-term care facilities and in geriatric wards is less developed. A disparity was found between the available services and those most appropriate to take care of the three cases described in the vignettes, especially for the patient dying from non-malignant diseases. The survey also demonstrated that caregivers are not well prepared to care for the elderly palliative patient at home or in nursing homes.

Conclusion

One of the challenges for the years to come will be to develop palliative care structures adapted to the needs of the elderly in Europe, but also to improve the education of health professionals in this field.     

Personalized Activity Intelligence (PAI) for Prevention of Cardiovascular Disease and Promotion of Physical Activity

Purpose

To derive and validate a single metric of activity tracking that associates with lower risk of cardiovascular disease mortality.

From the Cover: Global inequality remotely sensed

Economic inequality is notoriously difficult to quantify as reliable data on household incomes are missing for most of the world. Here, we show that a proxy for inequality based on remotely sensed nighttime light data may help fill this gap. Individual households cannot be remotely sensed. However, as households tend to segregate into richer and poorer neighborhoods, the correlation between light emission and economic thriving shown in earlier studies suggests that spatial variance of remotely sensed light per person might carry a signal of economic inequality. To test this hypothesis, we quantified Gini coefficients of the spatial variation in average nighttime light emitted per person. We found a significant relationship between the resulting light-based inequality indicator and existing estimates of net income inequality. This correlation between light-based Gini coefficients and traditional estimates exists not only across countries, but also on a smaller spatial scale comparing the 50 states within the United States. The remotely sensed character makes it possible to produce high-resolution global maps of estimated inequality. The inequality proxy is entirely independent from traditional estimates as it is based on observed light emission rather than self-reported household incomes. Both are imperfect estimates of true inequality. However, their independent nature implies that the light-based proxy could be used to constrain uncertainty in traditional estimates. More importantly, the light-based Gini maps may provide an estimate of inequality where previously no data were available at all.

Over the past decades, there has been a transition from theoretical to data-driven inequality research (1). However, progress is limited by a lack of data on economic prosperity at the household level (2) as well as the absence of consensus on ways of measuring economic inequality (3, 4). Practical constraints include limited coverage, incomparability at population subscales, dependence on misreported income surveys, and low-quality data collection in developing economies (5–7). Furthermore, since traditional inequality measures are not georeferenced at different geographic scales, they cannot be used in subregional studies. Thus, despite broad interest in inequality, empirical approaches remain contentious (8). Since the late twentieth century, initiatives like the World Income Inequality Database, the Luxembourg Income Study Database, and the World Wealth and Income Database have partly filled this lacuna. However, these datasets still suffer from large regional variations in coverage, data quality, and lack of compatibility concerning collection methodologies (9, 10). The vast majority of publications in inequality research are based on data from North America and Western Europe (11). As a result, while inequality in the developed world is relatively well documented (12–14), our knowledge about inequality in the developing world is limited by paucity, poor quality, uncertainty, and incomparability of data (15, 16). This implies that we know the least about areas where inequality perhaps presents the most serious developmental policy challenge.Here, we suggest a way to use remotely sensed nighttime light (NTL) for filling this gap. NTL is a globally uniform metric reflecting the nocturnal anthropogenic use of lights (17, 18). Almost all economic activities occurring in postdaylight hours, be it consumption or production, require the use of artificial lights, an assertion corroborated by studies showing NTL to be highly related with indicators of economic activity (19–22).     

Proline conformation-dependent antimicrobial activity of a proline-rich histone h1 N-terminal Peptide fragment isolated from the skin mucus of Atlantic salmon

A 30-residue N-terminally acetylated peptide derived from the N-terminal part of histone H1 was identified as the dominant antimicrobial peptide in skin mucus from Atlantic salmon (Salmo salar). The peptide (termed salmon antimicrobial peptide [SAMP H1]) was purified to homogeneity by a combination of reversed-phase and cation-exchange chromatographies. By Edman degradation of the deacetylated peptide and by sequencing of the PCR-amplified DNA that encodes the peptide, the complete amino acid sequence was determined to be AEVAPAPAAAAPAKAPKKKAAAKPKKAGPS. The theoretical molecular weight of N-terminally acetylated SAMP H1 was calculated to be 2,836, which is the same as that determined by matrix-assisted laser desorption ionization mass spectrometry. The peptide was active against both gram-negative and -positive bacteria. The N-terminal acetyl group was not necessary for activity since deacetylation did not reduce the activity. A synthetic peptide whose sequence was identical to that of the isolated fragment was initially inactive but could be activated by binding it to a cation-exchange column. Treatment of the synthetic peptide when it was bound to the exchange column with peptidylproline cis-trans-isomerase increased the amount of active peptide, indicating that isomerization of the proline peptide bond(s) was necessary for activation of the synthetic peptide. Comparison of the active and inactive forms by circular dichroism and chromatographic analyses suggests that the active form, both the natural and the synthetic forms, is more structured, condensed, and rigid than the inactive form, which has a more nonstructured conformation. This work shows for the first time the importance of proline isomers in the activity of an antimicrobial peptide.     

Possibilities, limitations, and technique for the study of regional myocardial perfusion in man by Xenon-133.

The theoretical possibilities and the practical limitations of the Xenon-133 (133Xe) method for the study of regional myocardial perfusion in man are discussed. The techniques for data acqusition and processing developed over the past 5 years are described in detail. Illustrative examples of experimental findings are reported. The practical interpretation of the data, at the light of the influence of injection site, initial tracer distribution, constancy of counting geometry, spatial resolution, and Xenon retention in fat, is presented.     

Impact of chronic patency of infarct-related coronary artery on prevalence of myocardial ischemia during the pharmacologic and exercise stress test

Background: Even late restoration of anterograde coronary flow may have beneficial effects on left ventricular function, electrophysiology, and survival in postinfarction patients. Hypothesis: The patency or occlusion of an infarct-related coronary artery in the chronic phase may also be associated with myocardial ischemia provoked by pharmacologic and physiologic stress tests. Methods: High-dose dipyridamole echocardiography test (DET) (up to 0.84 mg/kg over 10 min), exercise electrocardiography (EET), and coronary angiographic data in a group of 127 in-hospital patients who had survived an acute myocardial infarction were analyzed. Patients who had only angiographic evidence of infarct-related single artery disease (≥50% luminal diameter reduction) and no previous revascularization were enrolled in the study. DET and EET were performed (DET in all, EET in 118 patients) within 5 days before coronary angiography. Fifty-seven patients had total occluded infarct arteries (Group 1) with various degrees of collateral circulation (2.6±1.1 collateral score, by a 3 grading system), whereas the other 70 patients had patent infarct arteries (Group 2) with significant residual stenoses (82±13% diameter reduction). Results: The prevalence of rest angina or effort angina and topography of the infarct-related coronary artery did not differ between the two groups (all p = NS). There were more patients with Q wave in Group 1 than in Group 2 (72 vs. 57%, p = 0.08) compared with non-Q wave infarction (Group 1 = 28 vs. Group 2 = 43%, p = 0.08). Ischemia in the infarct-related artery territory detected by DET (defined as new wall motion dyssynergy or marked worsening of resting hypokinesia) was 61% in Group 1 and 41% in Group 2 (p = 0.025). EET was positive in 26 of 54 (48%) Group 1 and in 21 of 64 (33%) Group 2 patients (p = 0.09). Conclusions: Patients with occluded infarct-related arteries have a higher prevalence of ischemia during DET and EET regardless of the presence of collateral flow. These results suggest that the presence of partial anterograde flow in the prolonged period could have a favorable influence on prevalence of residual ischemia in these patients.     

Ueber Schädelbasisbrüche

Ohne Zusammenfassung     

A solitary manifestation of mastocytosis in the head and neck

Solitary mastocytosis in adulthood is a rare finding. Only two such lesions have been reported in the head and neck. We describe a 27-year-old woman who had a 10-year history of a forehead swelling that had fluctuated in size. Light trauma or pressure on the lesion resulted in an increase in its size. A mass was found to be situated just below the galea and was successfully removed surgically using a high forehead lift. Histologically, the specimen contained predominantly mast cells. A systemic mastocytosis was excluded by a multidisciplinary diagnostic approach and measurement of the 24-h urinary excretion of histamine metabolites. After 36 months of follow-up there has been no recurrence. Received: 20 May 1999 / Accepted: 15 July 1999