[Operative risk of geriatric patients in cardiac surgery]. / Operatives Risiko geriatrischer Patienten in der Herzchirurgie.

BACKGROUND: Despite substantial progress in interventional cardiology, there are still many geriatric patients who require cardiac surgery. Estimation of the operative risk is therefore of great importance. OBJECTIVE: The prognostic value of the geriatric assessment for estimation of the operative risk was evaluated. MATERIAL AND METHODS: Between 2008 and 2009 a geriatric assessment was carried out on 500 patients before an urgent or elective cardiac surgery intervention. The primary endpoints were in-hospital death, death within 30 days after the intervention and stroke. A secondary endpoint was the combination of death, stroke and in-hospital complications. RESULTS: The average age of the patients was 77.1 ± 4.6 years and 44.3% of the particpants were women. Aortic stenosis was the primary reason for surgery in 49.2% of patients and coronary artery disease in 38.8% of patients. Half of the patients (56.5%) showed functional impairments in one or more evaluated domains. Significant limitations in cognitive function were present in 11.8% and in mobility in 2.4% of the patients. The 30-day mortality was 2.9% and stroke occurred in 1.4% of the patients. After multivariate analysis cognitive impairment remained independently associated with the operative mortality (odds ratio OR 3.8, 95% confidence interval CI 1.2-12.7). CONCLUSION: The perioperative mortality of older patients in cardiac surgery is low. A limited functional status detected in the geriatric assessment is associated with an increased mortality. Impaired cognitive function is an independent predictor of postoperative mortality.

[Pharmacist rounds on geriatric wards : Assessment of 1 year of pharmaceutical counseling]. / Pharmazeutische Visite auf geriatrischen Stationen : Auswertung der pharmazeutischen Empfehlungen eines Jahres.

BACKGROUND: Older patients suffer more often from drug-induced complications. OBJECTIVE: What are the precise recommendations pharmacists can give to geriatricians? MATERIAL AND METHODS: Two pharmacists conducted clinical rounds on 2 geriatric wards over a period of 54 weeks. Protocols of conspicuous medications for geriatric patients were analyzed and suggestions were made. RESULTS: Particularly frequent were the questionable medical indications for proton pump inhibitors, allopurinol, pregabalin and gabapentin. Adjustment of the dosage of heparin and its analogs to impaired renal function of patients was often lacking. This was also occasionally the case for metformin, some antibiotics and simvastatin. There were several interactions of drug combinations with a high risk for QT prolongation. The inhibition of resorption of bisphosphonates and L­thyroxin by the simultaneous intake of magnesium and calcium seemed to be probable. Furthermore, it was noticed that for some medications for patients treated by percutaneous endoscopic gastrostomy (PRG) administration by feeding tubes was not possible and combinations of different eye drops which should not be applied simultaneously but at delayed time intervals. CONCLUSION: An additional medication-related visit provides an interventional option for avoidance of medication errors.

[Special care units for acutely ill patients with cognitive impairment in Germany. Position paper]. / Spezialstation für akut erkrankte, kognitiv eingeschränkte Patienten in Deutschland. Positionspapier.

BACKGROUND: Dementia is an increasing challenge for care providers in nursing homes and hospitals. Since the 1980s, special acute care units in nursing homes have developed rapidly. In Germany, the first unit in a hospital opened in 1990. In 2013, there were 22 units. MATERIALS AND METHODS: In the following paper, the German Geriatric Society ("Deutsche Gesellschaft für Geriatrie e. V.") recommends basic standards for these wards. RESULTS: The basic standards for these wards include the following: a maximum of 20 beds, an area physically separated from the geriatric hospital department, their own dayroom and therapy room, a structured daily routine suitable for patients with dementia, the selection of permanent staff on a voluntary basis, specialized training, extended geriatric assessment, and special consideration of the background and social situation of the patients.

[Dementia: diagnosis and therapy]. / Demenz: Diagnostik und Therapie.

Dementia is a clinical syndrome characterized by progressive memory loss. Alzheimer's disease, a neurodegenerative disorder, accounts for the majority of clinical cases. The differential diagnosis comprises other neurodegenerative disease entities and vascular dementia, but also secondary and potentially reversible disturbances of cognitive function such as delirium or depression. Diagnostic work-up consists of standardized cognitive testing, neuroimaging, and a basic laboratory test battery. Pharmacological treatment of cognitive symptoms is accompanied by pharmacological and nonpharmacological treatment of psychiatric and behavioral symptoms, establishment of a supportive social network, as well as prevention and treatment of medical complications of dementia. This article summarizes current clinical knowledge on dementia and has a special interest in treatment and prophylaxis of complications in the field of internal medicine.

Treatment of dementia patients with fracture of the proximal femur in a specialized geriatric care unit compared to conventional geriatric care.

To prove the efficiency of a specialized geriatric ward (cognitive geriatric unit, CGU) for patients with a fracture of the proximal femur and additional dementia, we conducted a matched-pair analysis comparing 96 patients with fracture of the proximal femur and additional dementia matched for age, sex, surgical treatment and the degree of cognitive impairment by MMSE score. A total of 48 patients were treated in the CGU, offering extended geriatric assessment, special education of staff, and architecture appropriate for patients with cognitive decline. Target criteria were a gain in the Barthel index and Tinetti score, the length of stay, new admissions to nursing home, the frequency of neuroleptic, antidepressant, and antidementive medication, and the number of specified clinical diagnoses for the dementia syndrome. Length of stay was significantly longer in the CGU. The increase of the Tinetti score was significantly higher in the patients in the CGU, regardless of the length of stay (analysis of covariance: treatment (CGU/non-CGU): F(1/93) = 9.421, p = 0.003; covariate (length of stay): F(1/93) = 3.452, p = 0.066, η(2) = 3.6%). In the intervention group, the number of definite diagnoses concerning the dementia syndrome was also higher. Comparison of drug treatment and the percentage of new admission to a nursing home did not differ between groups. Treatment in a specialized, "cognitive geriatric unit" seems to result in better mobility of demented patients with proximal fractures of the femur.

Adrenergic modulation of sharp wave-ripple activity in rat hippocampal slices.

Norepinephrine (NE) has been shown to facilitate learning and memory by modulating synaptic plasticity in the hippocampus in vivo. During memory consolidation, transiently stored information is transferred from the hippocampus into the cortical mantle. This process is believed to depend on the generation of sharp wave-ripple complexes (SPW-Rs), during which previously stored information might be replayed. Here, we used rat hippocampal slices to investigate neuromodulatory effects of NE on SPW-Rs, induced by a standard long-term potentiation (LTP) protocol, in the CA3 and CA1. NE (10-50 µM) dose-dependently and reversibly suppressed the generation of SPW-Rs via activation of α1 adrenoreceptors, as indicated by the similar effects of phenylephrine (100 µM). In contrast, the unspecific ß adrenoreceptor agonist isoproterenol (2 µM) significantly increased the incidence of SPW-Rs. Furthermore, ß adrenoreceptor activation significantly facilitated induction of both LTP and SPW-Rs within the CA3 network. Suppression of SPW-Rs by NE was associated with a moderate hyperpolarization in the majority of CA3 pyramidal cells and with a reduction of presynaptic Ca(2+) uptake in the stratum radiatum. This was indicated by activity-dependent changes in [Ca(2+) ](o) and Ca(2+) fluorescence signals, by changes in the paired pulse ratio of evoked EPSPs and by analysis of the coefficient of variance. In the presence of NE, repeated high frequency stimulation (high-frequency stimulation (HFS)) failed to induce SPW-Rs, although SPW-Rs appeared following washout of NE. Together, our data indicate that the NE-mediated suppression of hippocampal SPW-Rs depends on α1 adrenoreceptor activation, while their expression and activity-dependent induction is facilitated via ß1-adrenoreceptors.

[Special care units for the treatment of acutely ill, cognitively impaired geriatric patients in Germany]. / Spezialisierte Stationen zur Behandlung von akut erkrankten geriatrischen Patienten mit zusätzlichen kognitiven Beeinträchtigungen in Deutschland.

During recent years, specialized wards have been established in geriatric hospital departments as a consequence of the growing need of special care for acutely ill older patients, who are also cognitively impaired. However, there are neither established standards nor any commonly agreed concept of care. A written survey among 12 specialized wards in Germany revealed some characteristics of these wards: extended geriatric assessment, special education of staff including validation and gerontopsychiatric issues, and particular equipment/architecture, such as hidden doors and group rooms, and in some cases loop tracks for walking, therapeutic facilities, and 'living rooms' on the wards. There is a wide variability with respect to the designation of these wards, the number of beds, length of stay, and admission criteria. It appears from this survey that there should be an exchange of empirical experience made on these wards, and there is a need of collaborative research on its usefulness.

Bioelectric impedance phase angle is associated with hospital mortality of geriatric patients.

Malnutrition is regularly associated with weight loss and changes in body composition, which lead to an increase in disability, complications and mortality. Bioelectric impedance analysis (BIA) is a simple and non-invasive bedside body composition analysis technique. In particular, bioelectric impedance phase angle (PA) has been shown to predict prognosis and mortality in several clinical conditions. The purpose of this study was to determine the relationship of BIA measurements and hospital mortality in multimorbid geriatric patients. The data obtained from the routine clinical admissions of 1071 consecutive patients (783 women and 288 men, age 81.4±8.5 years) to a geriatric hospital unit was analyzed retrospectively. A significant difference of PA (50 kHz) between survivors (4.2±1.1°) and non-survivors (3.6±1.2°; p<0.001) of the hospital stay could be detected. Subjects with a PA below 3.5° showed a significant fourfold increased hospital mortality of 20% (95% CI=15-24%) compared to all other subjects (5%; 95% CI=4-7%). No calculated parameters of BIA reflecting body composition were associated with hospital mortality. Although the extent to which the PA may be regarded as a marker of nutritional state is still controversial, it was associated with hospital mortality in geriatric patients.

Nutritional and hydration status in elderly subjects: clinical rating versus bioimpedance analysis.

Malnutrition and dehydration are common in elderly. A simple, reliable instrument to assess nutritional and hydration status would be very helpful. Bioelectrical impedance analysis (BIA) has been promising in this context, but data of elderly persons and geriatric in-hospital patients are rare. Therefore, we first compared BIA measurements (resistance, reactance, phase angle and a resulting vectorgraph) with a clinical assessment in 31 community-dwelling women and 30 female nursing-home residents. The results of the BIA measurement correlated well to weight, hand grip strength, and calf circumference. We then compared BIA measurements with clinical judgement of hydration status in 103 acute geriatric hospital in-patients. Concordance between the results of clinical judgement and BIA measurements was only 43.7%. In assessing geriatric in-patients, there is little concordance between the clinical and the bioelectrical evaluation of the hydration status.

Visual search in patients with subcortical vascular dementia: short fixations but long reaction times.

Visual search is a cognitive function of high ecological relevance. It involves rapid alternations between allocating and shifting attention. In patients with Alzheimer's disease, the duration of fixations during visual search increases already in the early stage of the illness. Subcortical vascular dementia (SVD), a newly defined subgroup of vascular dementia, has not yet been examined in this respect. SVD affects patients with a history of lacunar infarctions and/or transient ischemic attacks, focal neurological signs and evidence of subcortical white matter lesions as well as lacunes in the deep grey matter. Here, we report our findings from tracking eye movements during a visual search task with different array sizes in 9 patients with SVD and compare the number and duration of eye fixations they made with the values obtained in 9 healthy elderly control subjects. While patients with SVD were significantly slower in the tasks with longer center to target distances (mean reaction time), the number and duration of fixations they made did not differ from those in controls. Impairment of visual search in patients with SVD seems to be an effect of general cognitive slowing in more demanding arrays of visual search rather than a specific deficit in parameters of eye fixation.

[What does the language of Alzheimer patients have to do with the language of Paul Celan?]. / Was die Sprache Alzheimer-Kranker mit der Celans verbindet -- Uber Kommunikation mit schwer betroffenen Demenzpatienten.

Being in touch with severely demented patients requires a fundamental transformation in communication habits in medicine and in nursing. There is a need of reorientation away from an interpreting and often deficit-oriented aspect of communication towards attentive observance of unusual verbal and nonverbal signals and resources of the patient. Spontaneous and open communication with the patient outweighs the importance of a goal-oriented exchange of information and poses a significant challenge for all health and social professions. The well-being of persons with dementia depends mainly on the quality of communication and on the design of the milieu and the quality of everyday life. Interaction in nursing seems to be the crucial issue, including both spontaneity and creativity in the interaction partners, while respecting the personal boundaries of both the patient and the nurse in the necessary intimacy of the care environment. This essay shows important aspects and strategies of adequate communication with people with dementia from the perspective of medicine and of nursing. Ways to improve communication skills are shown, referring, among others, to the approaches by Kate Allan and John Killick (research fellows at Dementia Services Development Centre, University of Stirling).

[Medicine in old age and in the elderly. Educational concepts in area Q7 of the accreditation requirements and its first evaluation by students]. / Medizin des Alterns und des alten Menschen Unterrichtskonzept im Querschnittsbereich Q7 der Approbationsordnung und erste Evaluierung durch Studierende.

Until very recently, medicine in old age was not an obligatory part of the medical students' education in Germany. This has been changed by an educational reform. However, there are no obliging recommendations or procedures on which issues of medicine in old age should be taught. Therefore, we describe the development of a new curriculum, first experiences with the teaching, and the results of its evaluation by the students at the University of Hamburg. As a result, the subjects and the didactic teaching were both well accepted by the students and judged as interesting and instructive.

Solution self-assembly of hybrid block copolymers containing poly(ethylene glycol) and amphiphilic beta-strand peptide sequences.

The self-assembly in aqueous solution of hybrid block copolymers consisting of amphiphilic beta-strand peptide sequences flanked by one or two PEG chains was investigated by means of circular dichroism spectroscopy, small-angle X-ray scattering, and transmission electron microscopy. In comparison with the native peptide sequence, it was found that the peptide secondary structure was stabilized against pH variation in the di- and tri-block copolymers with PEG. Small-angle X-ray scattering indicated the presence of fibrillar structures, the dimensions of which are comparable to the estimated width of a beta-strand (with terminal PEG chains in the case of the copolymers). Transmission electron microscopy on selectively stained and dried specimens shows directly the presence of fibrils. It is proposed that these fibrils result from the hierarchical self-assembly of peptide beta-strands into helical tapes, which then stack into fibrils.

Effects of arousing emotional scenes on the distribution of visuospatial attention: changes with aging and early subcortical vascular dementia.

BACKGROUND: The modulation of attention by emotionally arousing stimuli is highly important for each individual's social function. Disturbances of emotional processing are a supportive feature for the diagnosis of subcortical vascular dementia (SVD). We address here whether these disturbances might be useful as an early disease marker. METHODS: In order to examine the modulation of visual attention by emotionally arousing stimuli of different valence, 12 elderly patients with early SVD, 12 age-comparable healthy adults and 12 young healthy subjects were studied while looking at pairs of pictures from the International Affective Picture Battery that were either neutral-neutral, neutral-positive or neutral-negative in terms of emotional content. Eye movements were recorded with an infrared eye-tracking system. The direction of the first saccade and the dwell time during the 10 s of presentation were measured and compared among groups with parametric tests. RESULTS: All subjects showed a modulation of initial attentional orienting as well as a higher percentage of dwell time towards the pictures containing emotional material. Patients with SVD and old controls did not differ in either experimental measure. Young patients showed a stronger bias towards emotionally negative material than both groups of older individuals. CONCLUSIONS: Modulation of visuospatial attention is preserved in early SVD. This might have implications for therapeutic interventional approaches. A weakened sustained attention towards negative but not positive emotional pictures in the elderly is in accordance with the socioemotional selectivity theory, describing a relative selection of positive stimuli with aging.

[Subacute proximal entrapment neuropathy of the radial nerve at the hiatus radialis]. / Subakutes proximales Engpasssyndrom des N. radialis im Hiatus radialis.

Endogenous lesions of the radial nerve at the upper arm level and in the canalis spiralis are exceptional. Entrapment of the radial nerve in the hiatus radialis following forced arm movements, stretching, or as a consequence of pathologies of the surrounding tissue is known. We observed two patients suffering from a painful subacute middle radial nerve palsy with complete axonal degeneration caused by a lesion at the hiatus radialis, demonstrated by EMG, sonography, MRI, and surgical exploration. Successful nerve repair, in one case with a nerve graft, was performed. In both cases the most appropriate explanation was a focal neuritis with swelling of the nerve followed by strangulation at the hiatus radialis. In one case acute neuroborreliosis was the reason for the neuritis.

Binding N2, N2H2, N2H4, and NH3 to transition-metal sulfur sites: modeling potential intermediates of biological N2 fixation.

In the quest for low-molecular-weight metal sulfur complexes that bind nitrogenase-relevant small molecules and can serve as model complexes for nitrogenase, compounds with the [Ru(PiPr(3))('N(2)Me(2)S(2)')] fragment were found ('N(2)Me(2)S(2)'(2-)=1,2-ethanediamine-N,N'-dimethyl-N,N'-bis(2-benzenethiolate)(2-)). This fragment enabled the synthesis of a first series of chiral metal sulfur complexes, [Ru(L)(PiPr(3))('N(2)Me(2)S(2)')] with L=N(2), N(2)H(2), N(2)H(4), and NH(3), that meet the biological constraint of forming under mild conditions. The reaction of [Ru(NCCH(3))(PiPr(3))('N(2)Me(2)S(2)')] (1) with NH(3) gave the ammonia complex [Ru(NH(3))(PiPr(3))('N(2)Me(2)S(2)')] (4), which readily exchanged NH(3) for N(2) to yield the mononuclear dinitrogen complex [Ru(N(2))(PiPr(3))('N(2)Me(2)S(2)')] (2) in almost quantitative yield. Complex 2, obtained by this new efficient synthesis, was the starting material for the synthesis of dinuclear (R,R)- and (S,S)-[micro-N(2)[Ru(PiPr(3))('N(2)Me(2)S(2)')](2)] ((R,R)-/(S,S)-3). (Both 2 and 3 have been reported previously.) The as-yet inexplicable behavior of complex 3 to form also the R,S isomer in solution has been revealed by DFT calculations and (2)D NMR spectroscopy studies. The reaction of 1 or 2 with anhydrous hydrazine yielded the hydrazine complex [Ru(N(2)H(4))(PiPr(3))('N(2)Me(2)S(2)')] (6), which is a highly reactive intermediate. Disproportionation of 6 resulted in the formation of mononuclear diazene complexes, the ammonia complex 4, and finally the dinuclear diazene complex [micro-N(2)H(2)[Ru(PiPr(3))('N(2)Me(2)S(2)')](2)] (5). Dinuclear complex 5 could also be obtained directly in an independent synthesis from 1 and N(2)H(2), which was generated in situ by acidolysis of K(2)N(2)(CO(2))(2). Treatment of 6 with CH(2)Cl(2), however, formed a chloromethylated diazene species [[Ru(PiPr(3))('N(2)Me(2)S(2)')]-micro-N(2)H(2)[Ru(Cl)('N(2)Me(2)S(2)CH(2)Cl')]] (9) ('N(2)Me(2)S(2)CH(2)Cl'(2-) =1,2-ethanediamine-N,N'-dimethyl-N-(2-benzenethiolate)(1-)-N'-(2-benzenechloromethylthioether)(1-)]. The molecular structures of 4, 5, and 9 were determined by X-ray crystal structure analysis, and the labile N(2)H(4) complex 6 was characterized by NMR spectroscopy.

The fuzzy frontier between subjective memory complaints and early dementia. A survey of patient management in German memory clinics.

BACKGROUND: Mild cognitive decline is frequent in the elderly population. Whether it is related to normal aging or an early phase of evolving dementia is difficult to ascertain with confidence, and accordingly there is a lack of consensus guidelines for diagnosis and therapy in such patients. We assessed the variability with which memory clinics deal with this problem in everyday practice. METHODS: We sent three fictitious case histories to all 85 German memory clinics that contained the results of clinical examination and neuropsychological test scores and asked for diagnosis and patient management. Patient 1 presented with complaints of mental decline but normal neuropsychological and neurological evaluation and normal daily living activities. Patient 2 came in as a control subject for a study and had impaired test scores but preserved daily living activities, and patient 3 was brought in by relatives with slight impairment of daily living activities and decline in some neuropsychological test scores but relatively spared memory scores. RESULTS: Most of the 51 respondents agreed in recommending further neuropsychological testing, a basic laboratory work-up, brain imaging, and a re-examination after 3-6 months. Yet, there was a high variability in the diagnostic terms used, in the additional diagnostic procedures proposed, and in the recommendations concerning therapeutic intervention and driving. CONCLUSIONS: The results reveal a need of practice guidelines for the use of diagnostic terms, therapeutic interventions and driving recommendations in patients between subjective memory complaints and early dementia.

[Visual search in healthy persons and Alzheimer's patients: relating cognitive function to clinical practice]. / "Visuelles Suchen" bei Gesunden und Patienten mit Alzheimer-Erkrankung. Verknüpfung von kognitiver Grundlagenforschung und klinischer Praxis.

Visual search is a complex and highly relevant cognitive task. Hypotheses about the processes involved have been derived from experimental psychology and modified by recent functional imaging methods revealing the underlying neuronal networks. To close the gap between theoretical implications and clinical practice, models of visual search are employed to explain visual search impairments in patients with Alzheimer's disease.

Central hyperacusis with phonophobia in multiple sclerosis.

Hearing disorders are a well-described symptom in patients with multiple sclerosis (MS). Unilateral or bilateral hyperacusis or deafness in patients with normal sound audiometry is often attributed to demyelinating lesions in the central auditory pathway. Less known in MS is a central phonophobia, whereby acoustic stimuli provoke unpleasant and painful paresthesia and lead to the corresponding avoidance behaviour. In our comparison collective, patient 1 described acute shooting pain attacks in his right cheek each time set off by the ringing of the telephone. Patient 2 complained of intensified, unbearable noise sensations when hearing nonlanguage acoustic stimuli. Patient 3 noticed hearing unpleasant echoes and disorders of the directional hearing. All patients had a clinical brainstem syndrome. ENT inspection, sound audiometry and stapedius reflex were normal. All three patients had pathologically changed auditory evoked potentials (AEPs) with indications of a brainstem lesion, and in magnetic resonance imaging (MRI) demyelinating lesions in the ipsilateral pons and in the central auditory pathway. The origin we presume in case 1 is an abnormal impulse conduction from the leminiscus lateralis to the central trigeminus pathway and, in the other cases, a disturbance in the central sensory modulation. All patients developed in the further course a clinically definite MS. Having excluded peripheral causes for a hyperacusis, such as, e.g., an idiopathic facial nerve palsy or myasthenia gravis, one should always consider the possibility of MS in a case of central phonophobia. Therapeutic possibilities include the giving of serotonin reuptake inhibitors or acoustic lenses for clearly definable disturbing frequencies.

Idiopathic inflammatory pseudotumor of the orbit and Tolosa-Hunt syndrome--are they the same disease?

Unilateral periorbital pain, cranial nerve palsies and a dramatic response to corticosteroid therapy are the hallmarks of clinical presentation in Tolosa-Hunt-Syndrome (THS) and Idiopathic Pseudotumor of the Orbit (IIPO). Both are unspecific chronic granulomatous diseases of unknown origin, sharing clinical as well as paraclinical characteristics. We observed two patients suffering from acute granulomatous IIPO, who also fulfilled the criteria of THS. Patient 1 developed leftsided infiltration of the medial ocular muscle with periorbital pain and cranial nerve palsy. After an initial response to corticosteroid therapy, contralateral relapse occurred with a THS-like infiltration of the sinus cavernosus and narrowing of the intracavernous internal carotid artery. Granulomatous infiltration of the right sinus cavernosus with secondary involvement of the ipsilateral nervus opticus and a slight exophthalmos was seen in Case 2. According to the literature, MRI and CT show identical signal intensity with different localisation: IIPO preferentially intra- and THS retroorbital. Apart from neuroradiological findings, almost similar histopathology and clinical presentation makes it difficult to distinguish between these two syndromes. Similarities between these two syndromes have been discussed for more than 20 years. Our two cases show their close relationship and we suggest that both diseases belong to the same pathological process.