Genericity aspects in gravitational collapse to black holes and naked singularities

We investigate here the genericity and stability aspects for naked singularities and black holes that arise as the final states for a complete gravitational collapse of a spherical massive matter cloud. The form of the matter considered is a general Type I matter field, which includes most of the physically reasonable matter fields such as dust, perfect fluids and such other physically interesting forms of matter widely used in gravitation theory. We first study here in some detail the effects of small pressure perturbations in an otherwise pressure-free collapse scenario, and examine how a collapse evolution that was going to the black hole endstate would be modified and go to a naked singularity, once small pressures are introduced in the initial data. This allows us to understand the distribution of black holes and naked singularities in the initial data space. Collapse is examined in terms of the evolutions allowed by Einstein equations, under suitable physical conditions and as evolving from a regular initial data. We then show that both black holes and naked singularities are generic outcomes of a complete collapse, when genericity is defined in a suitable sense in an appropriate spac

Factors Associated with Sarcopenia and 7-Year Mortality in Very Old Patients with Hip Fracture Admitted to Rehabilitation Units: A Pragmatic Study

Background: Admitted bedridden older patients are at risk of the development of sarcopenia during hospital stay (incident sarcopenia). The objective of this study was to assess the factors associated with sarcopenia (incident and chronic) and its impact on mortality in older people with hip fracture. Methods: A multicenter, pragmatic, prospective observational study was designed. Older subjects with hip fracture admitted to two rehabilitation units were included. Sarcopenia was assessed at admission and at discharge according to the revised EWGSOP (European Working Group on Sarcopenia in Older People) consensus definition. The mortality was evaluated after 7 years of follow-up. Results: A total of 187 subjects (73.8% women) age 85.2 ± 6.3 years were included. Risk factors associated to incident and chronic sarcopenia were undernutrition (body mass index-BMI and Mini Nutritional Assessment-Short Form-MNA-SF), hand-grip strength and skeletal muscle index. During follow-up 114 patients died (60.5% sarcopenic vs. 39.5% non-sarcopenic, p = 0.001). Cox regression analyses showed that factors associated to increased risk of mortality were sarcopenia (HR: 1.67, 95% CI 1.11-2.51) and low hand-grip strength (HR: 1.76, 95% CI 1.08-2.88). Conclusions: Older patients with undernutrition have a higher risk of developing sarcopenia during hospital stay, and sarcopenic patients have almost two times more risk of mortality than non-sarcopenic patients during follow-up after hip fracture

Sacubitril-valsartan in heart failure and multimorbidity patients

Aims The poor control of symptoms in patients with advanced heart failure with reduced ejection function (HFrEF) can limit the functionality of patients. Sacubitril–valsartan, compared with enalapril, has been shown to reduce mortality and hospitalization, and nowadays, there is still little evidence about the improvement on functionality. The aim of our study is to analyse the improvement of the functional class and the 6 min walking test (6MWT) in patients with multiple pathologies and advanced heart failure. Methods and results From September 2016 to March 2018, 65 multimorbidity patients with severe symptomatic HFrEF were initiated to receive sacubitril–valsartan. Mean age was 78.6 ± 7.4 years, and 68% were male. The Charlson co-morbidity index was 8 points. Seventy-four per cent had New York Heart Association (NYHA) Functional Class IV. After the treatment, patients were able to achieve 55.68 m or more on 6MWT, and 91% presented an improvement in the NYHA functional class. Conclusions Sacubitril–valsartan relieves symptoms and improves functional class prognostic risk of patients with advanced HFrEF and co-morbidit

Genericity aspects in gravitational collapse to black holes and naked singularities

We investigate here the genericity and stability aspects for naked singularities and black holes that arise as the final states for a complete gravitational collapse of a spherical massive matter cloud. The form of the matter considered is a general Type I matter field, which includes most of the physically reasonable matter fields such as dust, perfect fluids and such other physically interesting forms of matter widely used in gravitation theory. We first study here in some detail the effects of small pressure perturbations in an otherwise pressure-free collapse scenario, and examine how a collapse evolution that was going to the black hole endstate would be modified and go to a naked singularity, once small pressures are introduced in the initial data. This allows us to understand the distribution of black holes and naked singularities in the initial data space. Collapse is examined in terms of the evolutions allowed by Einstein equations, under suitable physical conditions and as evolving from a regular initial data. We then show that both black holes and naked singularities are generic outcomes of a complete collapse, when genericity is defined in a suitable sense in an appropriate space.Comment: 24 pages, 6 figures, some changes in text and figures to match the version accepted for publication by IJMP

Nutritional Status and Nutritional Treatment Are Related to Outcomes and Mortality in Older Adults with Hip Fracture

Malnutrition is very prevalent in geriatric patients with hip fracture. Nevertheless, its importance is not fully recognized. The objective of this paper is to review the impact of malnutrition and of nutritional treatment upon outcomes and mortality in older people with hip fracture. We searched the PubMed database for studies evaluating nutritional aspects in people aged 70 years and over with hip fracture. The total number of studies included in the review was 44, which analyzed 26,281 subjects (73.5% women, 83.6 +/- 7.2 years old). Older people with hip fracture presented an inadequate nutrient intake for their requirements, which caused deterioration in their already compromised nutritional status. The prevalence of malnutrition was approximately 18.7% using the Mini-Nutritional Assessment (MNA) (large or short form) as a diagnostic tool, but the prevalence was greater (45.7%) if different criteria were used (such as Body Mass Index (BMI), weight loss, or albumin concentration). Low scores in anthropometric indices were associated with a higher prevalence of complications during hospitalization and with a worse functional recovery. Despite improvements in the treatment of geriatric patients with hip fracture, mortality was still unacceptably high (30% within 1 year and up to 40% within 3 years). Malnutrition was associated with an increase in mortality. Nutritional intervention was cost effective and was associated with an improvement in nutritional status and a greater functional recovery. To conclude, in older people, the prevention of malnutrition and an early nutritional intervention can improve recovery following a hip fracture

Muscle Loss: The New Malnutrition Challenge in Clinical Practice

Recent definitions of malnutrition include low muscle mass within its diagnostic criteria. In fact, malnutrition is one of the main risk factors of skeletal muscle loss contributing to the onset of sarcopenia. However, differences in the screening and diagnosis of skeletal muscle loss, especially as a result of malnutrition in clinical and community settings, still occur mainly as techniques and thresholds used vary in clinical practice. The objectives of this position paper are firstly to emphasize the link between skeletal muscle loss and malnutrition-related conditions and secondly to raise awareness for the timely identification of loss of skeletal muscle mass and function in high risk populations. Thirdly to recognize the need to implement appropriate nutritional strategies for prevention and treatment of skeletal muscle loss and malnutrition across the healthcare continuum. Malnutrition needs to be addressed clinically as a muscle-related disorder and clinicians should integrate nutritional assessment with muscle mass measurements for optimal evaluation of these two interrelated entities to tailor interventions appropriately. The design of monitoring/evaluation and discharge plans need to include multimodal interventions with nutrition and physical exercise that are key to preserve patient’s muscle mass and function in clinical and community settings

Influencia de la situación de desnutrición e impacto de la suplementación nutricional oral sobre la salud muscular y la mortalidad en personas mayores con fractura de cadera

Introducción: La sarcopenia es un síndrome geriátrico caracterizado por la pérdida progresiva de masa, fuerza y función muscular, reconocido por la Organización Mundial de la Salud como una enfermedad (M62.84). El algoritmo propuesto por el grupo europeo de trabajo sobre la sarcopenia en las personas mayores (EWGSOP) coloca la medición de la fuerza muscular como primer paso para el diagnóstico de sarcopenia, seguido en caso de resultar positivo de la medición de la cantidad y calidad muscular. Hipótesis y objetivos: La hipótesis de este proyecto de investigación es que el estado nutricional y la salud muscular influyen sobre la recuperación tras una fractura de cadera y sobre la mortalidad. Los objetivos específicos de este proyecto de investigación son: (1) Describir cómo el estado nutricional y la intervención nutricional influyen sobre la evolución clínica y la mortalidad; (2) Valorar si la suplementación nutricional oral enriquecida en -hydroxi--metil-butirato (HMB) y vitamina D, mejora la masa muscular y marcadores del estado nutricional; (3) Identificar los factores asociados con la presencia de sarcopenia al ingreso (sarcopenia crónica) y con el desarrollo de sarcopenia durante la estancia hospitalaria (sarcopenia incidente), e investigar la influencia de la sarcopenia sobre el riesgo de mortalidad durante 7 años de seguimiento. Métodos: Para alcanzar los objetivos específicos planteados, se ha realizado una revisión científica, y se han evaluado dos poblaciones específicas: estudio HIPERPROT-GER (intervención hiperproteica en pacientes con fractura de cadera) y estudio PREFISSARC-GER (PREvalencia y FISiopatología de la SARCopenia en pacientes con fractura de cadera). Resultados: En relación al primer objetivo los resultados demuestran que en los pacientes con fractura de cadera la prevalencia de desnutrición es muy alta (siendo casi del 46%), y que esta se asocia con un riesgo aumentado de complicaciones y peor recuperación funcional. La desnutrición, independientemente del criterio utilizado para su definición, se asocia con un aumento de la mortalidad. La intervención nutricional mejora los parámetros nutricionales y se asocia con una mayor recuperación funcional tras la fractura de cadera. En relación al segundo objetivo los resultados obtenidos demuestran que una dieta enriquecida en HMB y vitamina-D mejora la masa muscular, y previene la pérdida de peso en pacientes mayores con fractura de cadera. Respecto al tercer objetivo los factores de riesgo asociados con la sarcopenia incidente y crónica fueron el IMC y el MNA-SF, la fuerza de prensión de la mano y el índice de masa muscular esquelética. Durante el seguimiento, murieron 114 pacientes (sarcopénicos 60,5% vs no sarcopénicos 39,5%, p = 0,001). El análisis de regresión de Cox mostró que los factores asociados con un mayor riesgo de mortalidad fueron la sarcopenia (HR 1,67, IC 95% 1,11-2,51) y la fuerza de prensión disminuida (HR 1,76, IC 95% 1,08-2,88). Conclusiones: La literatura científica pone de manifiesto la alta prevalencia de desnutrición en personas mayores con fractura de cadera. La suplementación nutricional oral enriquecida en HMB y vitamina-D evita la pérdida de peso y mejora la masa muscular en las personas mayores con fractura de cadera. Los pacientes mayores con desnutrición mostraron mayor riesgo de desarrollar sarcopenia durante la estancia hospitalaria. Además los pacientes sarcopénicos presentaron dos veces mayor riesgo de mortalidad que los pacientes no sarcopénicos durante el seguimiento tras una fractura de cadera. Por todo ello podemos concluir que, la prevención de la desnutrición podría contribuir en reducir la incidencia de fractura, que la suplementación nutricional contribuye en prevenir la pérdida de peso y en mejorar la masa muscular tras una fractura de cadera, y en último que la sarcopenia se asocia con un aumento de la mortalidad tras una fractura de cadera