Early interdisciplinary hospital intervention for elderly patients with hip fractures – functional outcome and mortality

OBJECTIVES: Hip fractures are associated with high levels of co-morbidity and mortality. Orthogeriatric units have been shown to be effective with respect to functional recovery and mortality reduction. The aim of this study is to document the natural history of early multidisciplinary intervention in elderly patients with hip fractures and to establish the prognostic factors of mortality and walking ability after discharge. METHODS: This observational, retrospective study was performed in an orthogeriatric care unit on patients aged >70 years with a diagnosis of hip fracture between 2004 and 2008. This study included 1363 patients with a mean age of 82.7 + 6.4 years. RESULTS: On admission to the unit, the average Barthel score of these patients was 77.2 + 27.8 points, and the average Charlson index score was 2.14 + 2.05. The mean length of stay was 8.9 + 4.26 days, and the readmission rate was 2.3%. The in-hospital mortality rate was 4.7%, and the mortality rates at one, six, and 12 months after discharge were 8.7%, 16.9%, and 25.9%, respectively. The Cox proportional hazards model estimated that male sex, Barthel scale, heart failure, and cognitive impairment were associated with an increased risk of death. With regard to functionality, 63.7% of the patients were able to walk at the time of discharge, whereas 77.4% and 80.1% were able to walk at one month and six months post-discharge, respectively. The factors associated with a worse functional recovery included cognitive impairment, performance status, age, stroke, Charlson score, and delirium during the hospital stay. CONCLUSIONS: Early multidisciplinary intervention appears to be effective for the management of hip fracture. Age, male sex, baseline function, cognitive impairment and previous comorbidities are associated with a higher mortality rate and worse functional recovery

Validation of score in mna scale like nutritional risk factor in institutionalized geriatric patients with moderate and severe cognitive impairment

Introducción: La valoración geriátrica integral incluye el examen del apartado nutricional debido a la alta prevalencia de desnutrición en este tipo de pacientes; especialmente en los pacientes con deterioro cognitivo asociado. Las escalas de cribado del estado nutricional presentan preguntas de autopercepción subjetiva de difícil respuesta en pacientes mayores con demencia. Objetivo: Estudiar la especificidad, el valor predictivo positivo y la sensibilidad de la escala MNA para la detección de malnutrición en pacientes diagnosticados de enfermedad de Alzheimer con deterioro cognitivo avanzado. Material y métodos: Se diseñó un estudio descriptivo poblacional con una muestra de 52 pacientes mayores de 70 años, institucionalizados, con enfermedad de Alzheimer grado moderado y severo. Se estudió la sensibilidad, especificidad y valor predictivo positivo de la escala MNA respecto a los parámetros de malnutrición del American Institute of Nutrition (AIN). Resultados: Los valores de sensibilidad, especificidad y valor predictivo positivo son 60%, 94,7% y 93,8% respectivamente. Existe una correlación significativa (p < 0,001) ente la puntuación obtenida en la escala MNA y la escala de riesgo de caídas Tinneti (r = 0,577), de función Barthel (r = 0,742), de valoración cognitiva MEC (r = 0,651) y los niveles de creatinina (r = 0,402). Más del 50% de la muestra presentó al menos un parámetro de malnutrición AIN alterado. Conclusiones: La escala MNA presenta una menor sensibilidad y especificidad en estos pacientes. El diseño de una escala de valoración nutricional sin valoraciones subjetivas y sólo con parámetros objetivos podría mejorar la eficacia de la misma en ancianos institucionalizados con deterioro cognitivo moderado y severo.Introduction: comprehensive geriatric assessment includes examination of the nutritional status given the high prevalence of hyponutrition in this kind of patients, particularly in patients with associated cognitive impairment. Scales for screening the nutritional status include questions on self-perception difficult to answer by demented elder patients. Objective: To study the specificity, the positive predictive value, and the sensitivity of the MNA scale to detect malnutrition in patients diagnosed with Alzheimer’s disease with advanced cognitive impairment. Material and methods: a population-based descriptive study with a sample of 52 patients older than 70 years, institutionalized, and with moderate-severe Alzheimer’s disease was designed. The sensitivity, specificity, and positive predictive value of MNA scale were studied regarding the parameters on malnutrition of the American Institute of Nutrition (AIN). Results: the sensitivity, specificity, and positive predictive values were 60%, 94.7%, and 93.8%, respectively. There was a significant correlation (p < 0.001) between the score obtained with the MNA Scale and the Tinneti’s Risk of Fall Scale (r = 0.577), the Barthel’s function (r = 0.742), the MCT cognitive assessment (r = 0.651), and creatinine levels (r = 0.402). More than 50% of the sample presented at least one malnutrition parameter altered. Conclusions: the MNA Scale presents lower sensitivity and specificity in these patients. Designing a nutritional assessment scale without subjective evaluations and only with objective parameters might improve its efficiency in institutionalized elderly patients with moderate-severe cognitive impairment.Nutrición humana y dietétic

Post-Franco Theatre

In the multiple realms and layers that comprise the contemporary Spanish theatrical landscape, “crisis” would seem to be the word that most often lingers in the air, as though it were a common mantra, ready to roll off the tongue of so many theatre professionals with such enormous ease, and even enthusiasm, that one is prompted to wonder whether it might indeed be a miracle that the contemporary technological revolution – coupled with perpetual quandaries concerning public and private funding for the arts – had not by now brought an end to the evolution of the oldest of live arts, or, at the very least, an end to drama as we know it

Dietary α‐Linolenic Acid, Marine ω‐3 Fatty Acids, and Mortality in a Population With High Fish Consumption: Findings From the PREvención con DIeta MEDiterránea (PREDIMED) Study

Background: Epidemiological evidence suggests a cardioprotective role of α‐linolenic acid (ALA), a plant‐derived ω‐3 fatty acid. It is unclear whether ALA is beneficial in a background of high marine ω‐3 fatty acids (long‐chain n‐3 polyunsaturated fatty acids) intake. In persons at high cardiovascular risk from Spain, a country in which fish consumption is customarily high, we investigated whether meeting the International Society for the Study of Fatty Acids and Lipids recommendation for dietary ALA (0.7% of total energy) at baseline was related to all‐cause and cardiovascular disease mortality. We also examined the effect of meeting the society's recommendation for long‐chain n‐3 polyunsaturated fatty acids (≥500 mg/day). Methods and Results: We longitudinally evaluated 7202 participants in the PREvención con DIeta MEDiterránea (PREDIMED) trial. Multivariable‐adjusted Cox regression models were fitted to estimate hazard ratios. ALA intake correlated to walnut consumption (r=0.94). During a 5.9‐y follow‐up, 431 deaths occurred (104 cardiovascular disease, 55 coronary heart disease, 32 sudden cardiac death, 25 stroke). The hazard ratios for meeting ALA recommendation (n=1615, 22.4%) were 0.72 (95% CI 0.56–0.92) for all‐cause mortality and 0.95 (95% CI 0.58–1.57) for fatal cardiovascular disease. The hazard ratios for meeting the recommendation for long‐chain n‐3 polyunsaturated fatty acids (n=5452, 75.7%) were 0.84 (95% CI 0.67–1.05) for all‐cause mortality, 0.61 (95% CI 0.39–0.96) for fatal cardiovascular disease, 0.54 (95% CI 0.29–0.99) for fatal coronary heart disease, and 0.49 (95% CI 0.22–1.01) for sudden cardiac death. The highest reduction in all‐cause mortality occurred in participants meeting both recommendations (hazard ratio 0.63 [95% CI 0.45–0.87]). Conclusions: In participants without prior cardiovascular disease and high fish consumption, dietary ALA, supplied mainly by walnuts and olive oil, relates inversely to all‐cause mortality, whereas protection from cardiac mortality is limited to fish‐derived long‐chain n‐3 polyunsaturated fatty acids. Clinical Trial Registration URL: http://www.Controlled-trials.com/. Unique identifier: ISRCTN35739639

Severity of cognitive impairment as a prognostic factor for mortality and functional recovery of geriatric patients with hip fracture

Aim To identify how the severity of dementia influences functional recovery and mortality in elderly patients hospitalized for hip fracture. Methods An observational retrospective study of 1258 patients aged older than 69 years and diagnosed with hip fracture who received care within an orthogeriatrics unit from 2004 to 2008 was carried out. During a 12‐month follow‐up period, functional recovery and mortality outcomes were measured. Results Dementia was present in 383 (28.1%) patients: it was mild in 183 (48%), moderate in 102 (26.5%) and severe in 98 (25.5%). Compared with patients with preserved cognitive status, patients with dementia had the following statistically significant differences (means [standard deviation] or percentage): older age (preserved, 82.29 years [6.5 years]; mild, 83.63 years [6.1 years]; moderate, 83.47 years [5.9 years]; severe, 84.46 years [6.1 years]; P < 0.001); lower Barthel Index (89.7 [21.6], 72.7 [24.6], 58.9 [28.6], 38.0 [28.1]; P < 0.001); delirium (11.7%, 25.6%, 37.6%, 44.7%; P < 0.001); less ambulation at 6 months postdischarge (83.9%, 72.8%, 56.9%, 41.7%; P < 0.001); and higher mortality at discharge (4%, 5.7%, 8.2%, 10.6%; P < 0.001) and 12 months after discharge (21.2%, 32.3%, 46.3%, 53.5%; P < 0.001). Patients with severe dementia had lower probability of functional recovery at discharge (OR 0.272, 95% CI 0.140–0.526, P < 0.001) and 6 months after discharge (OR 0.439, 95% CI 0.197–0.979, P = 0.04), as well as a greater probability of dying (HR 1.640, 95% CI 1.020–2.635, P = 0.04). Conclusions We observed higher 12‐month mortality and less functional recovery with increasing severity of dementia.Medicin

What is the impact of post‐radical prostatectomy urinary incontinence on everyday quality of life? Linking Pad usage and International Consultation on Incontinence Questionnaire Short‐Form (ICIQ‐SF) for a COMBined definition (PICOMB definition)

Aims: To identify the definition for urinary continence (UC) after radical prostatectomy (RP) which reflects best patients' perception of quality of life (QoL). Methods: Continence was prospectively assessed in 634 patients, 12 months after RP using the International Consultation on Incontinence Questionnaire Short‐Form (ICIQ‐SF) and the number of pads employed in a 24‐hour period (pad usage). We used the one‐way ANOVA technique with posthoc pairwise comparisons according to Scheffé's method (homogeneous subsets) for assessing the degree of QoL deficit related to urinary incontinence (UI). Results: The continence prevalence is 64.4%, 74.1%, 88.3%, and 35.8% using “0 pads,” “1 safety pad,” “1 pad,” and “ICIQ score 0” definitions, respectively. Pad usage is moderately strongly associated with ICIQ 1, 2, and 3 (ρ = 0.744, 0.677, and 0.711, respectively; p < 0.001). Concordance between classical UC definitions is acceptable between “0 pads—ICIQ score 0” (K = 0.466), but poor for “1 safety pad” and “1 pad” (K = 0.326 and 0.137, respectively). Patients with “0 pad usage” have better QoL related to urine leakage than patients with “1 safety pad” or “1 pad” (1.41 vs. 2.44 and 3.11, respectively; p < 0.05). There were no significant differences found regarding QoL between patients with ICIQ score 0 and ICIQ score 2 (1.01 vs. 1.63; p = 0.63).Conclusions: Pad usage and the ICIQ‐SF's answers provide useful information. We propose a combined definition (0 pads and ICIQ score ≤2) as it is the definition with the least impact on daily QoL

Benito Pérez Galdós

In Galdós\u27 time, the tensions between such diverse phenomena as coins and credit, free trade and protectionist tariffs, factory work and domestic economy, masculine and feminine, and private and public exacerbated friction among peoples—those of pueblo and rural origins, whose voices rasped and whose bright colors raked the eye, and a nascent, insecure bourgeosie who, fearful of the masses, strove to imitate the aristocracy. Old and new converged also with the question of suffrage and citizenship to aggravate social malaise and political upheavals—Carlist wars, palace intrigues, the Revolution of 1868 and overthrow of Queen Isabel, the brief reign of Amadeo of Savoy, the aborted First Republic and the Bourbon Restoration (1875-1885), which reached Spain from England in the imported person of Alfonso XII. These turbulent events undergird the cultural, historical, and political events of the novels by Benito Pérez Galdós (1843–1920) to be discussed in this chapter. Galdós is the author of seventy-seven novels, twenty-six original plays, and numerous occasional pieces, written between 1867 and 1920. These divide into two main categories: the historical and the contemporary social novels, now more appropriately described as novels of modernity The forty-six historical novels, called Episodios nacionales, make up five series, each consisting of ten interconnected novels, except the fifth series, left unfinished. The thirty-one novels of modernity, published between 1870 and 1915, also divide into two groups: Novelas de la primera época ( Novels of the Early Period, 1870–1879) and Las novelas de la serie contemporánea ( The Contemporary Social Novels, 1881–1915). The novels of the early period comprise Galdós\u27 first attempts at novel writing, as well as four so-called thesis novels : Doña Perfecta (1876), the sequel Gloria (1876–1877), Marianela (1878), and La familia de León Roch ( The Family of León Roch, 1878–1879). The next group of novels represents what Galdós called his segunda manera —his second style, a different kind of writing ... a more sophisticated and varied mode of narrative presentation