Diagnostic accuracy of the 'Dysphagia Screening Tool for Geriatric Patients' (DSTG) compared to Flexible Endoscopic Evaluation of Swallowing (FEES) for assessing dysphagia in hospitalized geriatric patients - a diagnostic study.

BACKGROUND: Oropharyngeal dysphagia is highly prevalent among hospitalized geriatric patients. The screening instruments used to date have been evaluated primarily in stroke patients. This diagnostic study aimed to validate a new screening instrument for oropharyngeal dysphagia, the 'Dysphagia Screening Tool for Geriatric Patients' (DSTG), as compared to one of the gold standards, flexible endoscopic evaluation of swallowing (FEES). MATERIALS AND METHODS: Geriatric inpatients admitted to five geriatric hospitals in Germany were consecutively evaluated using both DSTG and FEES in random order and by different evaluators blinded to the results of the other evaluation. In the FEES examination, a score of more than 3 on Rosenbek's Penetration Aspiration Scale was considered evidence of clinically relevant oropharyngeal dysphagia. Sensitivity, specificity and further measures of test performance were calculated for DSTG. RESULTS: The 53 volunteers recruited were on average 85 years of age, 56.6% were women. Twenty patients (37.7%) were diagnosed with dysphagia using FEES. Of these, 12 were screened as positive on DSTG. Of the 33 FEES negative patients, 4 tested positive on DSTG. The following test parameters were calculated for DSTG: sensitivity: 0.60, 95% confidence interval [0.39 ; 0.78], specificity 0.88 [0.73 ; 0.95], positive predictive value 0.75 [0.51 ; 0.90], negative predictive value 0.78 [0.63 ; 0.89], positive likelihood ratio 4.95 [1.85 ; 13.27], negative likelihood ratio 0.46 [0.26 ; 0.79]. In a receiver-operator characteristic (ROC) curve analysis, the area under the curve (AUC) was 0.77 [0.62 ; 0.91]. No adverse events occurred. CONCLUSION: The DSTG appears to be a valid instrument for screening of oropharyngeal dysphagia in geriatric inpatients.

[Development of a new screening instrument for screening of dysphagia in geriatric patients: the dysphagia screening tool geriatrics]. / Entwicklung eines neuen Screeninginstruments zum Screening auf Dysphagie bei geriatrischen Patienten: das Dysphagie Screening-Tool Geriatrie.

BACKGROUND: Oropharyngeal dysphagia is widespread in geriatric patients and is nearly always multicausal. It is often insufficiently recognized and leads to severe complications. The available and established screening tools all focus primarily on patients with neurological diseases, usually following a stroke. MATERIAL AND METHODS: The working group on dysphagia of the German Society of Geriatrics (DGG), which is comprised of physicians, speech and language therapists and dysphagia therapists, performed a literature review on dysphagia screening tools. Based on the results of the literature search and own experience, a new screening instrument suitable for geriatric patients was developed and agreed by the consensus group. RESULTS: The new screening instrument for the detection of oropharyngeal dysphagia in geriatric patients consists of three parts: 1) consciousness and posture control while sitting, 2) ability to swallow saliva and to cough as well as tongue motility and 3) the water swallowing test. The screening can be applied by trained medical personnel and can easily be integrated into everyday practice. CONCLUSION: The new screening tool is especially aimed at geriatric patients. It has advantages compared to previously recommended screening tests. Initial experiences with the instrument show good practicability and acceptance in geriatric teams. Further studies have to test the validity of the instrument.

Surgical revision of radial head fractures: a multicenter retrospective analysis of 466 cases.

BACKGROUND: Radial head fractures lead to persisting disability in a considerable number of cases. This study aimed to investigate their most common revision causes and procedures. METHODS: This multicenter retrospective study reviewed the cases of 466 adult patients who had undergone surgical revision after operative or nonoperative treatment of a radial head fracture. The initial diagnosis was a Mason type I fracture in 13.0%, Mason type II fracture in 14.6%, Mason type III fracture in 22.8%, Mason type IV fracture in 20.9%, terrible-triad injury in 12.8%, Monteggia-like lesion in 13.1%, and Essex-Lopresti lesion in 2.0%. Initial treatment was nonoperative in 30.2%, open reduction and internal fixation (ORIF) in 44.9%, radial head arthroplasty in 16.6%, radial head resection in 3.7%, sole treatment of concomitant injuries in 2.6%, and fragment excision in 2.0%. Up to 3 revision causes and procedures were recorded per case. RESULTS: The most common complications were stiffness (67.4%), instability (36.5%), painful osteoarthritis (29.2%), ORIF related (14.8%), nonunion or necrosis (9.2%), radial head arthroplasty related (7.5%), ulnar neuropathy (6.0%), and infection (2.6%). Revision procedures frequently included arthrolysis (42.1%), arthroplasty (24.9%), implant removal (23.6%), ligament repair or reconstruction (23.0%), débridement (14.2%), repeated ORIF (8.2%), and/or radial head resection (7.7%). Mason type I or II fractures were primarily revised because of stiffness and painful osteoarthritis. Complications after Mason type III fractures were predominantly ORIF related. Fracture-dislocations showed a wide range of complications, with instability and stiffness comprising the most common causes of revision. CONCLUSIONS: The complications of radial head fractures are characteristic to their classification. Knowledge of these findings might guide surgeons in treating these injuries and may help counsel patients accordingly.

New High-Power LEDs Open Photochemistry for Near-Infrared-Sensitized Radical and Cationic Photopolymerization.

Cyanines derived from heptamethines were investigated in combination with iodonium salts as initiators of the radical polymerization of tripropylene glycol diacrylate and epoxides derived from bisphenol-A-diglycidylether. A new near-infrared (NIR) LED prototype emitting at 805 nm with an exposure intensity of 1.2 W cm-2 facilitated initiation of both radical and cationic polymerization using sensitizers derived from cyanines. This new light-emitting device has brought new insight into the photochemistry of cyanines with the general structure 1 because a combination of photonic and thermal processes strongly influences reaction pathways. In particular, cationic cyanines comprising a cyclopentene moiety and diphenylamino group in the center initiated the cationic polymerization of epoxides. Selective oxidation of this unit explains why specifically these derivatives may function as initiators for cationic polymerization. In contrast, when the diphenylamino group was replaced by a barbital group at the meso-position cationic polymerization of epoxides was not initiated.

Outcome After Sentinel Lymph Node Dissection in Vulvar Cancer: A Subgroup Analysis of the AGO-CaRE-1 Study.

PURPOSE: Analyzing the large patient cohort of the multicenter AGO-CaRE-1 study, we compared isolated sentinel lymph node dissection (SLND) with radical lymph node dissection (LND) of the groin in relation to recurrence rates and survival. METHODS: The AGO-CaRE-1 study retrospectively collected data on treatment patterns and follow-up of vulvar cancer patients [International Federation of Gynecology and Obstetrics (FIGO) stage ≥1B] treated at 29 gynecologic cancer centers between 1998 and 2008. This subgroup analysis evaluated the influence of SLND alone on progression-free survival (PFS) and overall survival (OS). RESULTS: In 487 (63.1%) of 772 included patients with tumors smaller than 4 cm, an LND was performed and no metastatic lymph nodes were detected (LN0). Another 69/772 (8.9%) women underwent SLND alone, showing a negative SLN (SLN0). Tumors in the LN0 group were larger and showed a deeper invasion (LN0 vs. SLN0 tumor diameter: 20.0 vs. 13.0 mm, p < 0.001; depth of invasion: 4.0 vs. 3.0 mm, p = 0.002). After a median follow-up of 33 months (0-156), no significant differences in relation to isolated groin recurrence rates (SLN0 3.0% vs. LN0 3.4%, p = 0.845) were detected. Similarly, univariate 3-year PFS analysis showed no significant differences between both groups (SLN0 82.7% vs. LN0 77.6%, p = 0.230). A multivariate Cox regression analysis, including tumor diameter, depth of invasion, age, grading, and lymphovascular space invasion was performed: PFS [hazard ratio (HR) 0.970, 95% confidence interval (CI) 0.517-1.821] and OS (HR 0.695, 95% CI 0.261-1.849) did not differ significantly between both cohorts. CONCLUSION: This subgroup analysis of the large AGO-CaRE-1 study showed similar results for groin LND and SLND alone with regard to recurrence rates and survival in node-negative patients with tumors <4 cm.

Association of anemia with functional and nutritional status in the German multicenter study "GeriAnaemie2013".

OBJECTIVES: Anemia and malnutrition are risk factors for frailty in older people but data from multicenter studies among German geriatric inpatients are lacking. This analysis evaluated data from the multicenter study "GerAnaemie2013" commissioned by the German Geriatric Society. PATIENTS AND METHODS: The study involved an analysis of the 579 geriatric inpatients recruited in the context of the German multicenter study "GeriAnaemie2013". Study parameters: Barthel index (BI), handgrip strength, nutritional data (e.g. loss of appetite, loss of weight and decreased food intake). INCLUSION CRITERIA: in-patient age ≥70 years, exclusion criteria: current cancer disease or cancer-associated treatment. Anemia was defined according to the World Health Organization (WHO) criteria. RESULTS: The mean age of patients was 81.9 years, overall prevalence of anemia 55.1 %, mean hemoglobin (Hb) level 11.9 g/dl, average BI 50.8 points and 30.3 % of all patients were at risk of malnutrition. While univariate analysis revealed a significantly lower BI in anemic patients, this association was no longer seen in multivariate analysis. Regression analysis revealed that a drug intake of > 5 drugs/day doubles the chance of suffering from anemia with an adjusted odds ratio (OR) of 2.17 (confidence interval (CI) 1.28-3.68, p = 0.004) as well as a serum albumin level below 3.5 g/dl with an adjusted OR of 2.11 (range 1.40-3.19, p < 0.001). CONCLUSION: Polymedication and low serum albumin were independent risk factors for anemia in geriatric patients, probably reflecting disease severity.

Optimizing cofactor availability for the production of recombinant heme peroxidase in Pichia pastoris.

BACKGROUND: Insufficient incorporation of heme is considered a central impeding cause in the recombinant production of active heme proteins. Currently, two approaches are commonly taken to overcome this bottleneck; metabolic engineering of the heme biosynthesis pathway in the host organism to enhance intracellular heme production, and supplementation of the growth medium with the desired cofactor or precursors thereof to allow saturation of recombinantly produced apo-forms of the target protein. In this study, we investigated the effect of both, pathway engineering and medium supplementation, to optimize the recombinant production of the heme protein horseradish peroxidase in the yeast Pichia pastoris. RESULTS: In contrast to studies with other hosts, co-overexpression of genes of the endogenous heme biosynthesis pathway did not improve the recombinant production of active heme protein. However, medium supplementation with hemin proved to be an efficient strategy to increase the yield of active enzyme, whereas supplementation with the commonly used precursor 5-aminolevulinic acid did not affect target protein yield. CONCLUSIONS: The yield of active recombinant heme peroxidase from P. pastoris can be easily enhanced by supplementation of the cultivation medium with hemin. Thereby, secreted apo-species of the target protein are effectively saturated with cofactor, maximizing the yield of target enzyme activity.

Enzymatic degradability of diclofenac ozonation products: A mechanistic analysis.

The treatment of waterborne micropollutants, such as diclofenac, presents a significant challenge to wastewater treatment plants due to their incomplete removal by conventional methods. Ozonation is an effective technique for the degradation of micropollutants. However, incomplete oxidation can lead to the formation of ecotoxic by-products that require a subsequent post-treatment step. In this study, we analyze the susceptibility of micropollutant ozonation products to enzymatic digestion with laccase from Trametes versicolor to evaluate the potential of enzymatic treatment as a post-ozonation step. The omnipresent micropollutant diclofenac is used as an example, and the enzymatic degradation kinetics of all 14 detected ozonation products are analyzed by high-performance liquid chromatography coupled with high-resolution mass spectrometry (HPLC-HRMS) and tandem mass spectrometry (MS2). The analysis shows that most of the ozonation products are responsive to chemo-enzymatic treatment but show considerable variation in enzymatic degradation kinetics and efficiencies. Mechanistic investigation of representative transformation products reveals that the hydroxylated aromatic nature of the ozonation products matches the substrate spectrum, facilitating their rapid recognition as substrates by laccase. However, after initiation by laccase, the subsequent chemical pathway of the enzymatically formed radicals determines the global degradability observed in the enzymatic process. Substrates capable of forming stable molecular oxidation products inhibit complete detoxification by oligomerization. This emphasizes that it is not the enzymatic uptake of the substrates but the channelling of the reaction of the substrate radicals towards the oligomerization of the substrate radicals that is the key step in the further development of an enzymatic treatment step for wastewater applications.

Enzymatic post-treatment of ozonation: laccase-mediated removal of the by-products of acetaminophen ozonation.

Ozonation is a powerful technique to remove micropollutants from wastewater. As chemical oxidation of wastewater comes with the formation of varying, possibly persistent and toxic by-products, post-treatment of the ozonated effluent is routinely suggested. This study explored an enzymatic treatment of ozonation products using the laccase from Trametes versicolor. A high-performance liquid chromatography coupled with high-resolution mass spectrometry (HPLC-HRMS) analysis revealed that the major by-products were effectively degraded by the enzymatic post-treatment. The enzymatic removal of the by-products reduced the ecotoxicity of the ozonation effluent, as monitored by the inhibition of Aliivibrio fischeri. The ecotoxicity was more effectively reduced by enzymatic post-oxidation at pH 7 than at the activity maximum of the laccase at pH 5. A mechanistic HPLC-HRMS and UV/Vis spectroscopic analysis revealed that acidic conditions favored rapid conversion of the phenolic by-products to dead-end products in the absence of nucleophiles. In contrast, the polymerization to harmless insoluble polymers was favored at neutral conditions. Hence, coupling ozonation with laccase-catalyzed post-oxidation at neutral conditions, which are present in wastewater effluents, is suggested as a new resource-efficient method to remove persistent micropollutants while excluding the emission of potentially harmful by-products.

Low Self-Perception of Malnutrition in Older Hospitalized Patients.

BACKGROUND: Studies focusing on self-perception of nutritional status in older hospitalized patients are lacking. We aimed to examine the self-perception of body weight and nutritional status among older hospitalized patients compared to their actual body weight and nutritional status based on medical assessment. MATERIALS AND METHODS: This observational cross-sectional study investigated 197 older participants (mean age 82.2±6.8 years, 61% women) who were consecutively admitted to the geriatric acute care ward. Body weight status and nutritional status were assessed using WHO-BMI classification and Mini Nutritional Assessment-Short Form (MNA-SF), respectively. Self-perceived body weight status and nutritional status were assessed with a standardized questionnaire. A follow-up was performed with a short telephone interview after three months. RESULTS: According to MNA-SF, 49% and 35% were at risk of malnutrition and malnourished, respectively. There was no agreement between self-perceived nutritional status and objective nutritional status according to MNA-SF (Kappa: 0.06). A slight agreement was found between subjective body weight status and objective body weight status according to WHO-BMI classification (Kappa: 0.19). A total of 184 patients completed the 3 months follow-up and additional 9 patients died during this time, of which 7 and 2 were malnourished and at risk of malnutrition according to MNA-SF, respectively. Of those who were malnourished and at risk of malnutrition based on MNA-SF and died during follow-up, 67.7% did not realize their malnutrition. Compared to the patients with normal nutritional status during hospitalization, malnourished patients based on MNA-SF had higher rates of unplanned hospital readmission and further weight loss and more often reported health deterioration and experienced death within three months after discharge. CONCLUSION: No agreement between self-perceived nutritional status and objective nutritional status among older hospitalized patients was found. Our study highlights the need to raise knowledge about the issue of malnutrition and increase awareness of health risks associated with malnutrition among older hospitalized patients.

The GTPase Nog1 co-ordinates the assembly, maturation and quality control of distant ribosomal functional centers.

Eukaryotic ribosome precursors acquire translation competence in the cytoplasm through stepwise release of bound assembly factors, and proofreading of their functional centers. In case of the pre-60S, these steps include removal of placeholders Rlp24, Arx1 and Mrt4 that prevent premature loading of the ribosomal protein eL24, the protein-folding machinery at the polypeptide exit tunnel (PET), and the ribosomal stalk, respectively. Here, we reveal that sequential ATPase and GTPase activities license release factors Rei1 and Yvh1 to trigger Arx1 and Mrt4 removal. Drg1-ATPase activity removes Rlp24 from the GTPase Nog1 on the pre-60S; consequently, the C-terminal tail of Nog1 is extracted from the PET. These events enable Rei1 to probe PET integrity and catalyze Arx1 release. Concomitantly, Nog1 eviction from the pre-60S permits peptidyl transferase center maturation, and allows Yvh1 to mediate Mrt4 release for stalk assembly. Thus, Nog1 co-ordinates the assembly, maturation and quality control of distant functional centers during ribosome formation.

Association between hematologic parameters and functional impairment among geriatric inpatients: Data of a prospective cross-sectional multicenter study ("GeriPrävalenz2013").

OBJECTIVES: Objective of this study was to analyse the association between impairment of Barthel Index items and hematologic parameters in geriatric inpatients. METHODS: Patient recruitment of the "GeriPrävalenz2013" study has been described before. INCLUSION CRITERIA: in-patient aged>=70years; exclusion criteria: actual cancer disease or cancer associated treatment. Anemia was defined according to WHO criteria. Physical impairment was assessed by Barthel Index (BI). Association between all 10 items of the BI and hematologic parameters was statistically evaluated. RESULTS: Anemia prevalence was 55.1% (319/579) with BI impairment in 96.2% patients. T-test revealed significant lower BI in anemic patients (47.9 vs 54.3; p=0.004). Binary logistic regression revealed that growing age, reduced MCV, reduced iron levels and reduced Hb levels were associated with increased impairment of several items of the Barthel-Index. Interestingly, increased levels of albumin and folic acid (FA) were associated with increased impairment of BI items. CONCLUSION: Anemia and lower levels of anemia related parameters showed a negative impact on ADL and physical performance based on BI items. An impaired total BI should result in an analysis of BI subitems, particularly if anemia related laboratory parameters are deviant. Reasons for the negative impact of elevated FA and albumin levels on BI remain speculative.

Characterization of expressed pigmented core light harvesting complex (LH 1) in a reaction center deficient mutant of Blastochloris viridis.

The utility of photosynthetically defective mutants in the purple photosynthetic bacterium Blastochloris viridis (formerly Rhodopseudomonas viridis)was demonstrated with construction of a reaction-center deficient mutant, LH 1-H. This LH 1-H mutant has a photosynthetic apparatus in which most of the puf operon genes were deleted, resulting in an organism containing only the genes for the light harvesting polypeptides and the H subunit of the reaction center. This B. viridisstrain containing a truncation of the puf operon was characterized by gel electrophoresis, lipid-to-protein ratio analysis, optical spectroscopy, electron paramagnetic resonance and transmission electron microscopy. Optical and electron paramagnetic resonance spectroscopies revealed no photoactivity in this LH 1-H mutant consistent with the absence of intact reaction centers. Electron paramagnetic resonance evidence for assembled LH 1 complexes suggested that the interactions between light harvesting polypeptide complexes in membranes were largely unchanged despite the absence of their companion reaction center cores. The observed increase in the lipid-to-protein ratio was consistent with modified interactions between LH 1s, a view supported by transmission electron microscopy analysis of membrane fragments. The results show that B. viridis can serve as a practical system for investigating structure-function relationships in membranes and photosynthesis through the construction of photosynthetically defective mutants.

Guideline clinical nutrition in patients with stroke.

Stroke is regularly accompanied by dysphagia and other factors associated with decreased nutritional intake. Dysphagia with aspiration pneumonia and insufficient nutritional intake lead to worse outcome after stroke.This guideline is the first chapter of the guideline "Clinical Nutrition in Neurology" of the German Society for Clinical Nutrition (DGEM) which itself is one part of a comprehensive guideline about all areas of Clinical Nutrition. The thirty-one recommendations of the guideline are based on a systematic literature search and review, last updated December 31, 2011. All recommendations were discussed and consented at several consensus conferences with the entire DGEM guideline group. The recommendations underline the importance of an early screening and assessment of dysphagia and give advice for an evidence based and comprehensive nutritional management to avoid aspiration, malnutrition and dehydration.