Prognostic value of cardiac troponin I assay in hospitalized elderly patients.

BACKGROUND: Cardiac troponin I (cTnI) has been poorly studied in elderly inpatients. AIM: This study wanted to assess factors influencing the increase in cTnI and its prognostic value in hospitalized elderly patients. METHODS: 354 elderly (mean age of 84.8 ± 6.9 years) patients consecutively admitted in the Geriatrics Division in Padua were tested for cTnI levels assay during the hospital stay. Number of subsequent patient deaths at 6 months and 2 years were registered. RESULTS: Of the 354 patients, 27 (7.6%) died in hospital; their levels were not significantly higher or more frequently positive on cTnI than those of the remainder of the sample. 71 (20.01%) patients died within 6 months of being discharged, and in-hospital positive cTnI levels emerged as a mortality risk factor in this group [unadjusted HR 1.13 (1.04-1.23); p = 0.004]. At 2 years, a total of 174 patients (49.2%) had died, but in-hospital pathological cTnI levels were not a mortality risk factor in this group. DISCUSSION: It should be noted that cTnI level was a risk factor for mortality at 6 months but no longer at 2 years after an elderly patient's hospitalization. This finding may relate to patients' limited physiological reserves or be driven by the fact that the elderly tend to receive fewer evidence-based treatments, and to be managed more conservatively than younger patients. CONCLUSIONS: In the multidimensional analysis of older patients, troponin I can be used to stratify patients and assess mortality risk at 6 months, but not at 2 years.

Discussing end-of-life care issues with terminally ill patients and their relatives: comparisons among physicians, nurses and psychologists.

BACKGROUND AND AIMS: The aim of this study was to analyse the end-of-life topics most frequently discussed by Italian physicians, nurses and psychologists with terminally ill patients and their relatives. Findings were compared with the levels of communication reported by physicians in other countries involved in the EURELD research project, in Europe and elsewhere. METHODS: An ad hoc questionnaire was prepared to measure levels of communication and administered to 716 professionals (181 physicians, 454 nurses and 81 psychologists) employed in geriatric hospital wards, hospices and nursing homes, or registered with professional associations in the Veneto and Trentino Alto-Adige regions of north-east Italy. Statistical analyses (frequency analysis, multivariate logistic regression) were conducted on data from questionnaires returned by standard mail or email. RESULTS: Communication levels vary for the various end-of-life issues which physicians, nurses and psychologists are required to discuss and the individuals with whom they deal. Italian physicians are more communicative with relatives than with patients, whereas psychologists tend to discuss these problems more with patients than with members of their families. Nurses behave in much the same way with both patients and relatives. By comparison with their colleagues elsewhere in Europe, Italian physicians reveal more evident differences in their willingness to discuss end-of-life issues, depending on whether they are communicating with patients or relatives. Having received bio-ethical training helps physicians communicate with their patients. CONCLUSIONS: Communicating is a fundamental part of providing care for terminally ill patients and support for their families. The patient care process involves several kinds of professionals, who are all increasingly called upon to be prepared to discuss the end of a patient's life, and to develop a therapeutic relationship which includes communicating without evading any of the aspects (and problems) relating to this crucial final stage of an individual's life.

Advanced dementia: opinions of physicians and nurses about antibiotic therapy, artificial hydration and nutrition in patients with different life expectancies.

AIM: The aim of the present study was to investigate the proportion of physicians and nurses who agree with the administration of antibiotic therapy (AT), artificial hydration (AH), and artificial nutrition (AN) in patients with advanced dementia and different life expectancies. Furthermore, we aimed at analyzing the correlates of the opinion according to which medical treatments should no longer be given to advanced dementia patients once their life expectancy falls. METHODS: End-of-life decisions and opinions were measured with a questionnaire that was sent to geriatric units, hospices and nursing homes in three different regions of Italy. Multivariate logistic regressions were carried out to ascertain the correlates of the agreement with the administration of AH, AT or AN. RESULTS: When the patient's life expectancy was 1-6 months, 83% of respondents agreed with AH, 79% with AT and 71% with AN. When the life expectancy was less than 1 month, a large proportion of respondents still agreed with AH and AT (73% and 61%), whereas less than one in two respondents (48%) agreed with AN. CONCLUSIONS: The findings of the present study showed that AN creates more ethical dilemmas in the clinical management of end of life than other treatments, such as AH or AT. Opinions on whether or not these practices are appropriate at the end of life were related with feelings, thoughts and ethical issues that played a different part for physicians and nurses. Geriatr Gerontol Int 2017; 17: 487-493.

Short article: Relapsing Whipple's disease: a case report and literature review.

Whipple's disease is a rare infection caused by Tropheryma whipplei, a Gram-negative Bacillus usually found in macrophages of the lamina propria of the small intestine. The typical clinical manifestations of classic Whipple's disease are diarrhea, weight loss, malabsorption, abdominal pain, and arthralgia. The disease's laboratory diagnosis is currently based on duodenal biopsy. Treatment generally includes primary therapy for 2 weeks with intravenous antibiotics capable of reaching high levels in the cerebrospinal fluid, such as ceftriaxone, usually followed by treatment with oral cotrimoxazole for 1 year. Early diagnosis should enable appropriate treatment and improves the prognosis, and prolonged antibiotic treatment often leads to complete remission. Our case report focuses on a 72-year-old man who had been passing watery stools for 1-2 months, accompanied by low-grade fever. He reported profound asthenia, a weight loss of about 3 kg, and loss of appetite. Thirty years earlier (in 1984), he had been working as a horse keeper at a University Department of Agricultural and Veterinary Studies, where he had contracted Whipple's disease. Laboratory tests and microbiological studies led to a diagnosis of recurrent Whipple's disease. Esophagogastroduodenoscopy was performed under deep sedation. Biopsy samples obtained from the stomach and duodenum were stained with hematoxylin and eosin, Giemsa, and periodic acid-Schiff to identify any accumulation of typical periodic acid-Schiff-positive macrophages in the lamina propria. A specific quantitative real-time PCR assay using specific oligonucleotide probes for targeting repeated sequences of Tropheryma whipplei was also performed to detect its DNA in the duodenum samples.

Magnesium Status in Alzheimer's Disease: A Systematic Review.

The interest in poor magnesium (Mg) status as risk factor for Alzheimer's disease (AD) is increasing due to its antioxidant and neuroprotective properties. A systematic PubMed literature search of studies investigating Mg status was undertaken comparing AD to healthy controls (HCs) or patients with medical illness (medical controls [MCs]). Standardized mean differences (SMDs) ± 95% confidence intervals (CIs) were calculated for all outcomes. Of 192 potentially eligible studies, 13 were included (559 patients with AD, 381 HCs, and 126 MCs). Compared to HCs, patients with AD had significantly lower Mg in cerebrospinal fluid (2 studies; SMD = -0.35;P= .02) and in hair (2 studies; SMD = -0.75;P= .0001). No differences between AD and controls were evident for serum Mg. In conclusion, AD seems to be associated with a lower Mg status when compared to HCs, while the scarcity of studies limited the findings about MCs.

Short- and longer-term predictive capacity of the Multidimensional Prognostic Index: The timing of the assessment is of no consequence.

BACKGROUND: Several studies have tested the ability of the Multidimensional Prognostic Index (MPI) to predict mortality for acute elderly patients admitted to hospital. We compared the reliability of MPI scores obtained both on admission to, and at discharge from hospital. We tested MPI performance in predicting short- and longer-term mortality grouped into three risk groups and according to single MPI scores. METHODS: A longitudinal prospective study was conducted on 699 elderly patients admitted to the Geriatric Unit at Padua General Hospital. MPI scores were obtained on admission and at discharge. In-hospital and one-year mortality was recorded. Adjusted Cox's regression models were used to assess the prognostic value of the MPI scores. RESULTS: 691 were included in the study: 459 (66.4%) women and 232 (33.6%) men, mean age=85.2 ± 7.0 years. Patients were grouped as: low risk MPI 12.5%; moderate risk MPI 28.6%; severe risk MPI 58.9%. The cumulative in-hospital mortality rate was 7.4%. In the adjusted model, only MPI score (not MPI risk group) was significantly associated with in-hospital death ([HR]=1.22, 95%CI 1.07-1.39). 1-Year crude mortality rate: 39.2%. The patients' MPI scores at admission and at discharge were equally predictive of death (adjusted HR of MPI on admission 1.20 [1.15-1.27], p<0.0001; at discharge 1.24 [1.18-1.30], p<0.0001). The performance (AUC) of the MPI score on admission and at discharge proved much the same. CONCLUSIONS: This study confirmed the value of the MPI in predicting mortality for acute elderly patients. Grouping MPI scores into risk levels may not be appropriate when applied to hospitalized acute geriatric patients. The prognostic value of MPI scores was confirmed only for MPI value ≥0.68. Judging from our study, the timing of the assessment during a patient's hospital stay (on admission or at discharge) may be irrelevant for longer-term prognostic purposes.

Artificial nutrition and hydration in terminally ill patients with advanced dementia: opinions and correlates among Italian physicians and nurses.

BACKGROUND: Although their benefits are controversial, artificial nutrition and hydration are often administered as a form of basic care to terminally ill patients. An important reason for this may be that these treatments have strong emotional and psychological meanings. AIMS: In the present article we investigated the opinions of Italian physicians and nurses on the administration of artificial nutrition and hydration to terminally ill patients with advanced dementia. We also investigated the antecedents of these opinions, considering feelings and thoughts related to death, ethical issues and training in palliative care. METHOD: A questionnaire was administered to Italian physicians (n=288) and nurses (n=763). We analyzed the percentages of agreement with the administration of artificial nutrition and hydration and, using multivariate logistic regressions, the possible antecedents of these opinions. RESULTS: Agreement with the provision of artificial hydration was higher (73%) than for artificial nutrition (48%), suggesting that artificial hydration may be seen as a form of basic care. Agreement with their administration was generally lower among professionals in northern Italy working in geriatrics wards who had received training in palliative care. We also found that death-related feelings and thoughts and ethical issues played a different part for physicians and nurses. CONCLUSIONS: Our findings suggest that opinions concerning artificial nutrition and hydration not only derive from scientific background, but also relate to cultural, ethical, and psychological issues. Our results also reveal important differences between physicians' and nurses' opinions, providing useful information for interpreting and overcoming obstacles to the effective cooperation between these professionals.