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OBJECTIVE: To examine the role of eosinophils in the pre-diagnostic phase of inflammatory bowel disease (IBD), we studied the influence of genetic and shared environmental risk factors in a twin cohort of IBD. MATERIAL AND METHODS: We analysed eosinophil derived neurotoxin (EDN) and eosinophil cationic protein (ECP) in faecal samples from twin pairs with Crohn's disease (n = 37) or ulcerative colitis (n = 21) and from external healthy controls (n = 44). Eosinophils stained with eosinophil peroxidase (EPO) were quantified in rectal biopsies. Ratios with 95% confidence intervals were calculated. RESULTS: Twins with Crohn' disease displayed higher levels of EDN (Ratio = 2.98, 1.65-5.37) and ECP (Ratio 1.83, 1.24-2.70) than their healthy siblings. Levels did not differ between healthy twin-siblings and external controls (EDN, Ratio = 1.52, 0.79-2.94 and ECP, Ratio = 0.93, 0.56-1.54). Higher levels of EDN (Ratio = 2.43, 1.13-5.24) and ECP (Ratio = 1.53, 0.92-2.53) were observed among twins with ulcerative colitis vs their healthy siblings. Levels did not differ between healthy twin-siblings and external controls (EDN, Ratio = 1.08, 0.51-2.25 and ECP, Ratio = 1.29, 0.74-2.26). Using intra-class correlation coefficient (ICC), we found no agreement in levels of EDN or ECP in discordant pairs, except for ECP in monozygotic Crohn's disease pairs (ICC = 0.63). In contrast, agreement was observed in monozygotic pairs concordant for Crohn's disease (EDN, ICC = 0.67 and ECP, ICC = 0.66). The number of eosinophils in rectum was increased in twins with ulcerative colitis vs their healthy sibling (Ratio = 2.22, 1.50-3.27). CONCLUSIONS: Activation of eosinophils in IBD seems to be a consequence of inflammation rather than an effect of genetic and shared environmental risk factors alone.
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Eosinófilos , Doenças Inflamatórias Intestinais , Proteína Catiônica de Eosinófilo , Proteínas Granulares de Eosinófilos , Neurotoxina Derivada de Eosinófilo , Humanos , Doenças Inflamatórias Intestinais/genética , Fatores de RiscoRESUMO
BACKGROUND: The NAM-B1 gene in wheat has for almost three decades been extensively studied and utilized in breeding programs because of its significant impact on grain protein and mineral content and pleiotropic effects on senescence rate and grain size. First detected in wild emmer wheat, the wild-type allele of the gene has been introgressed into durum and bread wheat. Later studies have, however, also found the presence of the wild-type allele in some domesticated subspecies. In this study we trace the evolutionary history of the NAM-B1 in tetraploid wheat species and evaluate it as a putative domestication gene. RESULTS: Genotyping of wild and landrace tetraploid accessions showed presence of only null alleles in durum. Domesticated emmer wheats contained both null alleles and the wild-type allele while wild emmers, with one exception, only carried the wild-type allele. One of the null alleles consists of a deletion that covers several 100 kb. The other null-allele, a one-basepair frame-shift insertion, likely arose among wild emmer. This allele was the target of a selective sweep, extending over several 100 kb. CONCLUSIONS: The NAM-B1 gene fulfils some criteria for being a domestication gene by encoding a trait of domestication relevance (seed size) and is here shown to have been under positive selection. The presence of both wild-type and null alleles in domesticated emmer does, however, suggest the gene to be a diversification gene in this species. Further studies of genotype-environment interactions are needed to find out under what conditions selection on different NAM-B1 alleles have been beneficial.
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Evolução Molecular , Proteínas de Plantas/genética , Triticum/classificação , Triticum/genética , Alelos , Evolução Biológica , Grão Comestível , Variação Genética , Genótipo , Filogenia , TetraploidiaRESUMO
BACKGROUND: Cultivated crops have repeatedly faced new climatic conditions while spreading from their site of origin. In Sweden, at the northernmost fringe of Europe, extreme conditions with temperature-limited growth seasons and long days require specific adaptation. Pea (Pisum sativum L.) has been cultivated in Sweden for millennia, allowing for adaptation to the local environmental conditions to develop. To study such adaptation, 15 Swedish pea landraces were chosen alongside nine European landraces, seven cultivars and three wild accessions. Number of days to flowering (DTF) and other traits were measured and the diversity of the flowering time genes HIGH RESPONSE TO PHOTOPERIOD (HR), LATE FLOWERING (LF) and STERILE NODES (SN) was assessed. Furthermore, the expression profiles of LF and SN were obtained. RESULTS: DTF was positively correlated with the length of growing season at the site of origin (GSO) of the Swedish landraces. Alleles at the HR locus were significantly associated with DTF with an average difference of 15.43 days between the two detected haplotypes. LF expression was found to have a significant effect on DTF when analysed on its own, but not when HR haplotype was added to the model. HR haplotype and GSO together explained the most of the detected variation in DTF (49.6 %). CONCLUSIONS: We show local adaptation of DTF, primarily in the northernmost accessions, and links between genetic diversity and diversity in DTF. The links between GSO and genetic diversity of the genes are less clear-cut and flowering time adaptation seems to have a complex genetic background.
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Adaptação Biológica/genética , Flores/genética , Pisum sativum/genética , Evolução Biológica , Regulação da Expressão Gênica de Plantas , Genes de Plantas , Estudos de Associação Genética , Variação Genética , Fenótipo , Polimorfismo de Nucleotídeo Único , SuéciaRESUMO
BACKGROUND: Faecal biomarkers can be used to assess inflammatory bowel disease (IBD). AIM: To explore the performance of some promising biomarkers in diagnosing and predicting disease course in IBD. METHODS: We included 65 patients with treatment-naïve, new-onset Crohn's disease (CD), 90 with ulcerative colitis (UC), 67 symptomatic controls (SC) and 41 healthy controls (HC) in this prospective observational study. We analysed faecal samples for calprotectin (FC), myeloperoxidase (MPO), human neutrophil lipocalin (HNL), eosinophil cationic protein ECP and eosinophil-derived neurotoxin (EDN) and compared markers among groups. We assessed the diagnostic capability of biomarkers with receiver operating characteristic curves. Clinical disease course was determined for each patient with IBD and analysed the association with biomarkers by logistic regression. RESULTS: All markers were elevated at inclusion in patients with IBD compared with HC (p < 0.001) and SC (p < 0.001). FC (AUC 0.85, 95% CI: 0.79-0.89) and MPO (AUC 0.85, 95% CI: 0.80-0.89) showed the highest diagnostic accuracy in distinguishing IBD from SC. The diagnostic ability of biomarkers differed between IBD subtypes with the highest performance for FC and MPO in CD. The diagnostic accuracy was further improved by combining FC and MPO (p = 0.02). Levels of FC, MPO and HNL at inclusion were predictive of an aggressive disease course with MPO showing the strongest association (p = 0.006). CONCLUSIONS: This study provides new insight into the diagnostic and prognostic capability of neutrophil and eosinophil biomarkers in IBD and suggests that MPO, alone or in combination with FC, may add to the diagnostic power of faecal biomarkers.
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Biomarcadores , Colite Ulcerativa , Neurotoxina Derivada de Eosinófilo , Fezes , Complexo Antígeno L1 Leucocitário , Peroxidase , Humanos , Biomarcadores/análise , Biomarcadores/metabolismo , Feminino , Masculino , Fezes/química , Adulto , Estudos Prospectivos , Complexo Antígeno L1 Leucocitário/análise , Pessoa de Meia-Idade , Peroxidase/metabolismo , Colite Ulcerativa/diagnóstico , Neurotoxina Derivada de Eosinófilo/análise , Neurotoxina Derivada de Eosinófilo/metabolismo , Doença de Crohn/diagnóstico , Proteína Catiônica de Eosinófilo/análise , Proteína Catiônica de Eosinófilo/metabolismo , Adulto Jovem , Doenças Inflamatórias Intestinais/diagnóstico , Estudos de Casos e Controles , Curva ROC , Progressão da Doença , Valor Preditivo dos TestesRESUMO
INTRODUCTION: Fecal calprotectin (FC) is a noninvasive tool for examining response to biologics in inflammatory bowel disease (IBD), but its performance in relation to other novel fecal markers of various cellular origins is unknown. METHODS: We performed a prospective multicenter cohort study and included patients with active IBD who provided a fecal sample at initiation of biological therapy. Levels of FC, myeloperoxidase (MPO), human neutrophil lipocalin (HNL), and eosinophil-derived neurotoxin (EDN) were analyzed and related to clinical remission status at 3 months. Changes in levels of markers at 3 months were calculated, and the impact of concomitant use of corticosteroids at baseline was estimated. RESULTS: In patients achieving clinical remission (n = 27), a decrease in levels of FC ( P = 0.005), MPO ( P < 0.001), HNL ( P < 0.001), and EDN ( P < 0.001) was observed, whereas no significant decrease was seen in patients not achieving remission (n = 39). There was a significant difference in the change in the level of MPO ( P = 0.01) and HNL ( P = 0.02) between patients achieving clinical remission and those who did not, but changes in FC and EDN could not differentiate between these groups. Patients with concomitant systemic corticosteroids at inclusion had lower levels of HNL ( P = 0.01) and EDN ( P < 0.001) at baseline, compared with patients without corticosteroids. DISCUSSION: Fecal MPO, HNL, and EDN are all promising biomarkers for assessing the treatment outcome of biologics in patients with IBD. Fecal levels of EDN and HNL are significantly affected by corticosteroids indicating a greater sensitivity to the effects of corticosteroids compared with levels of FC and MPO.
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Doenças Inflamatórias Intestinais , Neutrófilos , Humanos , Eosinófilos , Estudos Prospectivos , Estudos de Coortes , Doenças Inflamatórias Intestinais/tratamento farmacológico , Lipocalinas , Biomarcadores , Neurotoxina Derivada de Eosinófilo , Corticosteroides/uso terapêutico , Terapia BiológicaRESUMO
This study compares the symptom profile of patients with postoperative delirium after femoral neck fracture surgery in those with and without dementia. In this study, 129 patients of age ≥70 years (mean age ±SD, 86±6 yr, 72% women) with postoperative delirium, were included. Delirium and dementia were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria. Of the 129 patients with delirium, 54 (42%) had a dementia disorder. Patients with delirium superimposed on dementia more often had any hyperactive and pure emotional delirium. Communication difficulties and symptoms such as restlessness/agitation, aggressive behavior, and irritability were more commonly found in the dementia group. In contrast, patients with delirium but without dementia were more often diagnosed with pure hypoactive and any psychotic delirium. The symptom profile of postoperative delirium varies according to whether it occurs in patients with or without dementia. This may indicate that postoperative delirium among patients with hip fracture differs based on the presence or absence of dementia.
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Delírio/diagnóstico , Delírio/psicologia , Demência/psicologia , Testes Neuropsicológicos/estatística & dados numéricos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/psicologia , Idoso de 80 Anos ou mais , Ritmo Circadiano , Delírio/complicações , Demência/complicações , Demência/diagnóstico , Feminino , Fraturas do Colo Femoral/psicologia , Fraturas do Colo Femoral/cirurgia , Avaliação Geriátrica/métodos , Avaliação Geriátrica/estatística & dados numéricos , Humanos , MasculinoRESUMO
Background: Improved mucosal immune profiling in active and quiescent colonic inflammatory bowel disease (IBD) is needed to develop therapeutic options for treating and preventing flares. This study therefore aimed to provide a comprehensive mucosal characterization with emphasis on immunological host response of patients with active ulcerative colitis (UC active), UC during remission (UC remission) and active colonic Crohn's disease (CD active). Methods: Colonic biopsies from 47 study subjects were collected for gene expression and pathway analyses using the NanoString host-response panel, including 776 genes and 56 immune-related pathways. Results: The majority of mucosal gene expression and signaling pathway scores were increased in active IBD (n=27) compared to healthy subjects (n=10). However, both active IBD and UC remission (n=10) demonstrated decreased gene expression and signaling pathway scores related to autophagy, alpha kinase-1 and IL-17 signaling pathways compared to healthy subjects. Further, UC remission was characterized by decreased scores of several signaling pathways linked to homeostasis along with increased mononuclear cell migration pathway score as compared to healthy subjects. No major differences in the colonic mucosal gene expression between CD active (n=7) and UC (n=20) active were observed. Conclusion: This study indicates that autophagy, alpha kinase-1 and IL-17 signaling pathways are persistently downregulated in UC irrespective of disease activity. Further, UC patients in remission present a unique mucosal environment, potentially preventing patients from reaching and sustaining true homeostasis. These findings may enable better comprehension of the remitting and relapsing pattern of colonic IBD and guide future treatment and prevention of flares.
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Clinical profiles of delirium in 717 older people with and without dementia age 75 years and older in 4 different types of care were studied. Delirium and dementia were diagnosed according to DSM-IV criteria. Delirious demented participants (n = 135) had more often had previous delirium episodes and were more often being treated with analgesics compared to delirious participants without dementia (n = 180). The clinical profile of delirium in the participants with dementia was more frequently characterized by aggressivity, latency in reaction to verbal stimuli, restlessness and agitation, delusions, anxiousness, hallucinations, and a poorer orientation and recognition. Delirium among demented participants more often had a fluctuating course during the day and was more common in the evening and at night. In conclusion, clinical profiles of delirium in participants with and without dementia are different, which might indicate a different etiology or pathophysiology, or both, and a need for different treatment strategies.
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Envelhecimento/psicologia , Delírio/epidemiologia , Delírio/psicologia , Demência/epidemiologia , Demência/psicologia , Idoso , Idoso de 80 Anos ou mais , Agressão/psicologia , Analgésicos/administração & dosagem , Ansiedade/epidemiologia , Ansiedade/psicologia , Ritmo Circadiano , Delusões/epidemiologia , Delusões/psicologia , Feminino , Avaliação Geriátrica/métodos , Avaliação Geriátrica/estatística & dados numéricos , Alucinações/epidemiologia , Alucinações/psicologia , Humanos , Masculino , Orientação , Escalas de Graduação Psiquiátrica/estatística & dados numéricos , Agitação Psicomotora/epidemiologia , Agitação Psicomotora/psicologia , Reconhecimento Psicológico , Suécia/epidemiologia , Comportamento VerbalRESUMO
OBJECTIVE: To investigate the short- and long-term effects of a multidisciplinary postoperative rehabilitation programme in patients with femoral neck fracture. DESIGN AND SUBJECTS: A randomized controlled trial in patients (n = 199) with femoral neck fracture, aged >or= 70 years. METHODS: The primary outcomes were: living conditions, walking ability and activities of daily living performance on discharge, 4 and 12 months postoperatively. The intervention consisted of staff education, individualized care planning and rehabilitation, active prevention, detection and treatment of postoperative complications. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation. A geriatric team assessed those in the intervention group 4 months postoperatively, in order to detect and treat any complications. The control group followed conventional postoperative routines. RESULTS: Despite shorter hospitalization, significantly more people from the intervention group had regained independence in personal activities of daily living performance at the 4- and 12-month follow-ups; odds ratios (95% confidence interval (CI) ) 2.51 (1.00-6.30) and 3.49 (1.31-9.23), respectively. More patients in the intervention group had also regained the ability to walk independently indoors without walking aids by the end of the study period, odds ratio (95% confidence interval) 3.01 (1.18-7.61). CONCLUSION: A multidisciplinary postoperative intervention programme enhances activities of daily living performance and mobility after hip fracture, from both a short-term and long-term perspective.
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Atividades Cotidianas , Fraturas do Colo Femoral/reabilitação , Caminhada , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas do Colo Femoral/fisiopatologia , Fraturas do Colo Femoral/cirurgia , Seguimentos , Avaliação Geriátrica , Humanos , Masculino , Atividade Motora , Equipe de Assistência ao Paciente , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/reabilitação , Recuperação de Função Fisiológica , Fatores de Tempo , Caminhada/fisiologiaRESUMO
Delirium on the day of admission to general internal medicine wards was studied in 400 consecutive patients aged 70 years and above regarding occurrence, associated factors, clinical profile, length of hospital stay, and mortality. The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination, and delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (4th ed) criteria. Delirium on the day of admission occurred in 31.3% of the patients and was independently associated with old age, fever on the day of admission (> or = 38 degrees C), treatment with neuroleptics, impaired vision, male sex, and previous stroke. Delirious patients had longer hospital stay (15.4 vs 9.5 days, P < .001), a higher mortality rate during hospitalization (11/125 vs 5/275, P < .001), and a higher 1-year mortality rate (45/125 vs 55/275, P = .001). Delirium is a common complication with often easily identified causes, and it has a serious impact on outcome for older medical patients.
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Delírio/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Delírio/epidemiologia , Delírio/mortalidade , Feminino , Hospitais Gerais , Humanos , Medicina Interna , Tempo de Internação , Masculino , Admissão do Paciente , Escalas de Graduação Psiquiátrica , Taxa de Sobrevida , Suécia/epidemiologia , Fatores de TempoRESUMO
A prospective inpatient study was performed at the Orthopedic and Geriatric Departments at the Umeå University Hospital, Sweden, to study inpatient falls, fall-related injuries, and risk factors for falls following femoral neck fracture surgery. Ninety-seven patients with femoral neck fracture aged 70 years or older were included, background characteristics, falls, injuries, and other postoperative complications were assessed and registered during the hospitalization. There were 60 postoperative falls among 26/97 patients (27%). The postoperative fall event rate was 16.3/1000 Days (95% CI 12.2-20.4). Thirty two percent of the falls resulted in injuries, 25% minor, and 7% serious ones. In multiple regression analyses, delirium after Day 7, HRR 4.62 (95% CI 1.24-16.37), male sex 3.92 (1.58-9.73), and sleeping disturbances 3.49 (1.24-9.86), were associated with inpatient falls. Forty-five percent of the patients were delirious the day they fell. Intervention programs, including prevention and treatment of delirium and sleeping disturbances, as well as better supervision of male patients, could be possible fall prevention strategies. Improvement of the quality of care and rehabilitation, with the focus on fall prevention based on these results, should be implemented in postoperative care of older people.
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Acidentes por Quedas/estatística & dados numéricos , Fraturas do Colo Femoral/epidemiologia , Fixação de Fratura/métodos , Pacientes Internados/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas do Colo Femoral/etiologia , Fraturas do Colo Femoral/cirurgia , Humanos , Incidência , Masculino , Estudos Prospectivos , Fatores de Risco , Suécia/epidemiologia , Índices de Gravidade do TraumaRESUMO
OBJECTIVES: To investigate whether an education program and a reorganization of nursing and medical care improved the outcome for older delirious patients. DESIGN: Prospective intervention study. SETTING: Department of General Internal Medicine, Sundsvall Hospital, Sweden. PARTICIPANTS: Four hundred patients, aged 70 and older, consecutively admitted to an intervention or a control ward. INTERVENTION: The intervention consisted of staff education focusing on the assessment, prevention, and treatment of delirium and on caregiver-patient interaction. Reorganization from a task-allocation care system to a patient-allocation system with individualized care. MEASUREMENTS: The patients were assessed using the Organic Brain Syndrome Scale and the Mini-Mental State Examination on Days 1, 3, and 7 after admission. Delirium was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. RESULTS: Delirium was equally common on the day of admission at the two wards, but fewer patients remained delirious on Day 7 on the intervention ward (n=19/63, 30.2% vs 37/62, 59.7%, P=.001). The mean length of hospital stay+/-standard deviation was significantly lower on the intervention ward then on the control ward (9.4+/-8.2 vs 13.4+/-12.3 days, P<.001) especially for the delirious patients (10.8+/-8.3 vs 20.5+/-17.2 days, P<.001). Two delirious patients in the intervention ward and nine in the control ward died during hospitalization (P=.03). CONCLUSION: This study shows that a multifactorial intervention program reduces the duration of delirium, length of hospital stay, and mortality in delirious patients.
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Delírio/terapia , Enfermagem Geriátrica/educação , Geriatria/educação , Capacitação em Serviço , Administração dos Cuidados ao Paciente/organização & administração , Idoso , Análise de Variância , Delírio/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Cuidados de Enfermagem/organização & administração , Prevalência , Relações Profissional-Paciente , Estudos Prospectivos , Suécia/epidemiologiaRESUMO
OBJECTIVES: To investigate whether delirium in older patients with femoral neck fractures is associated with an increased risk of developing dementia and a higher mortality rate. DESIGN: A 5-year prospective follow-up study. SETTING: Department of Orthopedic Surgery at the University Hospital in Umeå, Sweden. PARTICIPANTS: Seventy-eight nondemented patients aged 65 and older operated on for femoral neck fractures were followed for 5 years. MEASUREMENTS: The patients were assessed using the Organic Brain Syndrome (OBS) Scale pre- and postoperatively. Medical and social data were collected from the patients, their caregivers, and medical records, and the survivors were visited and assessed with the OBS Scale and the Mini-Mental State Examination in their homes 5 years after the fracture. RESULTS: Thirty of 78 (38.5%) nondemented patients with a femoral neck fracture developed dementia within a 5-year period. Twenty of 29 (69%) who were delirious postoperatively developed dementia, compared with 10 of 49 (20%) who were not delirious during their hospital stay (P <.001). Twenty-one (72.4%) of those with postoperative delirium died within 5 years, compared with 17 of 49 (34.7%) of those who remained lucid postoperatively (P =.001). CONCLUSION: Delirium in nondemented femoral neck fracture patients is associated with the development of dementia and a higher mortality rate. Patients with preoperative or postoperative delirium should therefore be assessed not only for the etiology of the delirium but also for any underlying organic brain disorder. Questions that remain unanswered are whether postoperative delirium is a marker of undetected dementia and whether postoperative delirium contributes to the development of dementia.
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Delírio/complicações , Delírio/mortalidade , Demência/etiologia , Demência/mortalidade , Fraturas do Colo Femoral/complicações , Fraturas do Colo Femoral/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas do Colo Femoral/cirurgia , Seguimentos , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Período Pós-Operatório , Cuidados Pré-Operatórios , Estudos Prospectivos , Escalas de Graduação Psiquiátrica , Medição de Risco , Fatores de TempoRESUMO
BACKGROUND: People with cognitive impairment and dementia have a poor outcome after a hip fracture surgery, about 30-50% of all those who sustain a hip fracture have dementia. Therefore the aim was to investigate whether a multidisciplinary postoperative intervention program could reduce postoperative complications and improve functional recovery among people with dementia. METHODS: A randomized controlled trial with subgroup analyses among patients with dementia. Sixty-four patients with femoral neck fracture, aged ≥70 years at Umeå University Hospital, Sweden. The intervention consisted of staff education, individualized care planning and rehabilitation, active prevention, detection and treatment of postoperative complications, especially delirium. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation, including a follow-up at 4 months postoperatively. The control group followed conventional postoperative routines. RESULTS: There were fewer postoperative complications in the intervention group such as urinary tract infections, p=0.001; nutritional problems, p=0.025; postoperative delirium, p=0.002; falls, p=0.006. At 4 months a larger proportion in the intervention group had regained their previous independent indoor walking ability performance, p=0.005. At 12 months a larger proportion in the intervention group had regained the activities of daily living (ADL) performance level they had before the fracture, p=0.027. CONCLUSION: This study demonstrates that patients with dementia who suffer a hip fracture can benefit from multidisciplinary geriatric assessment and rehabilitation and should not be excluded from rehabilitation programs.
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Demência/epidemiologia , Fraturas do Quadril/reabilitação , Acidentes por Quedas/prevenção & controle , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Delírio/prevenção & controle , Feminino , Avaliação Geriátrica , Fraturas do Quadril/epidemiologia , Humanos , Masculino , Distúrbios Nutricionais/prevenção & controle , Equipe de Assistência ao Paciente , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/reabilitação , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Suécia/epidemiologia , Resultado do Tratamento , Infecções Urinárias/prevenção & controle , Caminhada/estatística & dados numéricosRESUMO
BACKGROUND: About one third of hip-fractured patients have dementia and thus may have difficulties adhering to postoperative instructions. Hip replacement is the most common treatment when a femoral neck fracture is displaced in healthy older people, whereas for those with dementia and other severe comorbidities, internal fixation (IF) is generally recommended. PURPOSE: To evaluate complications, functional outcome, and mortality for both surgical methods, IF and hemiarthroplasty (HAP), in older patients suffering from femoral neck fracture with or without dementia. SAMPLE: One hundred eighty patients, aged 70 years or older, who were operated on using IF (n = 69) in undisplaced femoral neck fracture and HAP (n = 111) if the fractures were displaced. DATA COLLECTION: Mental state was assessed using the Mini-Mental State Examination and Organic Brain Syndrome scale, and dementia and delirium were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria. Outcomes of mortality, complications, functional ability, and quality of life were measured. FINDINGS: There was no difference in complications or mortality at 4 months and 1 year for the IF or HAP groups. Patients with and without dementia, operated on with HAP, had a better functional outcome after 1 year than those operated on with IF. The result of this study indicates that dementia per se is not a reason for disqualifying those patients from the most appropriate surgical method.
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Fraturas do Fêmur/cirurgia , Saúde Mental , Feminino , Fraturas do Fêmur/psicologia , Humanos , MasculinoRESUMO
AIMS: To investigate whether a nutritional intervention in older women and men with femoral neck fracture had an effect on postoperative complications during hospitalization and on nutritional status at a four-month follow-up. METHODS: The design was a randomized controlled trial. The present study sample consisted of 157 patients aged 70 years and above with femoral neck fracture. The nutritional intervention included, among other things, a nutritional journal to detect nutrition deficiencies and protein-enriched meals for at least four days postoperatively. Further, at least two nutritional and protein drinks were served each day during the whole hospitalization and other factors that would influence the patient's nutrition were also considered and dealt with. Postoperative complications were registered and patients were assessed using the Mini Nutritional Assessment (MNA) scale, including body mass index (BMI), on admission and at a four-month follow-up. RESULTS: Malnutrition was common and low MNA scores were associated with postoperative complications such as delirium and decubitus ulcers. There were significantly fewer days of delirium in the intervention group, seven patients in the intervention group developed decubitus ulcers vs. 14 patients in the control group and the total length of hospitalization was shorter. There were no detectable significant improvements regarding nutritional parameters between the intervention and the control group at the four-month follow-up but men improved their mean BMI, body weight and MNA scores in both the intervention and the control groups while women deteriorated in both groups. CONCLUSIONS: Malnutrition was common among older people with hip fractures admitted to hospital. The nutritional intervention might have contributed to the patients suffering fewer days with delirium, fewer decubitus ulcers and shorter hospitalization but did not improve the long-term nutritional status, at least not in women. RELEVANCE TO CLINICAL PRACTICE: This nutritional intervention, which was included in a multifactorial multidisciplinary intervention, is inexpensive and relatively easy to implement. It has significant effects on complications but no long-term effect on nutritional parameters, at least not in women.
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Fraturas do Quadril/complicações , Desnutrição/complicações , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , MasculinoRESUMO
BACKGROUND AND AIMS: Delirium is a common postoperative complication in elderly patients which has a serious impact on outcome in terms of morbidity and costs. We examined whether a postoperative multi-factorial intervention program can reduce delirium and improve outcome in patients with femoral neck fractures. METHODS: One hundred and ninety-nine patients, aged 70 years and over (mean age+/-SD, 82+/-6, 74% women), were randomly assigned to postoperative care in a specialized geriatric ward or a conventional orthopedic ward. The intervention consisted of staff education focusing on the assessment, prevention and treatment of delirium and associated complications. The staff worked as a team, applying comprehensive geriatric assessment, management and rehabilitation. Patients were assessed using the Mini Mental State Examination and the Organic Brain Syndrome Scale, and delirium was diagnosed according to DSM-IV criteria. RESULTS: The number of days of postoperative delirium among intervention patients was fewer (5.0+/-7.1 days vs 10.2+/-13.3 days, p=0.009) compared with controls. A lower proportion of intervention patients were delirious postoperatively than controls (56/102, 54.9% vs 73/97, 75.3%, p=0.003). Eighteen percent in the intervention ward and 52% of controls were delirious after the seventh postoperative day (p<0.001). Intervention patients suffered from fewer complications, such as decubitus ulcers, urinary tract infections, nutritional complications, sleeping problems and falls, than controls. Total postoperative hospitalization was shorter in the intervention ward (28.0+/-17.9 days vs 38.0+/-40.6 days, p=0.028). CONCLUSIONS: Patients with postoperative delirium can be successfully treated, resulting in fewer days of delirium, fewer other complications, and shorter length of hospitalization.
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Delírio/terapia , Fraturas do Colo Femoral/cirurgia , Complicações Pós-Operatórias/terapia , Idoso , Idoso de 80 Anos ou mais , Delírio/etiologia , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Fatores de TempoRESUMO
The aim of this study was to describe risk factors for delirium and the impact of delirium on the rehabilitation outcome for patients operated for femoral neck fractures. Sixty-one patients, aged 70 years or older, consecutively admitted to the Department of Orthopaedic Surgery at Umeå University Hospital, Sweden for femoral neck fractures were assessed and interviewed during hospitalization and at follow up 4 months after surgery. Delirium occurred in 38 (62%) patients and those who developed delirium were more often demented and/or depressed. Patients with delirium were longer hospitalized and they were more dependent in their activity of daily living (ADL) on discharge and after 4 months. They had poorer psychological well-being and more medical complications than the nondelirious. A large proportion of the patients who developed delirium did not regain their previous walking ability and could not return to their prefracture living accommodation. Delirium after hip fracture surgery is very common especially among patients with dementia or depression. This study shows that delirium has a serious impact on the rehabilitation outcome from both short- and long-term perspectives. Because delirium can be prevented and treated, it is important to improve the care of elderly patients with hip fractures.
Assuntos
Delírio/etiologia , Fraturas do Colo Femoral/complicações , Fraturas do Colo Femoral/reabilitação , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Delírio/epidemiologia , Delírio/prevenção & controle , Demência/complicações , Depressão/complicações , Feminino , Fraturas do Colo Femoral/cirurgia , Seguimentos , Fixação Interna de Fraturas/métodos , Avaliação Geriátrica , Necessidades e Demandas de Serviços de Saúde , Hospitais Universitários , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Saúde Mental , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/normas , Qualidade da Assistência à Saúde , Fatores de Risco , Inquéritos e Questionários , Suécia/epidemiologia , Resultado do TratamentoRESUMO
Much of chronic disease management depends on active partnership of consumer and provider. Our system promotes diabetes management through profiling and adaptive support of both consumer and provider. We use a University Podiatry Clinic and diabetes consumer information portal as inter-related contexts that share profile information.
Assuntos
Diabetes Mellitus/terapia , Gerenciamento Clínico , Hipermídia , Relações Profissional-Paciente , Doença Crônica , Correio Eletrônico , Humanos , Internet , Educação de Pacientes como Assunto , Participação do Paciente , Podiatria , Interface Usuário-ComputadorRESUMO
BACKGROUND: Delirium is a common neuropsychiatric syndrome characterized by disturbance of attention and consciousness developing over a short period of time. Symptoms tend to fluctuate during the course of the day. Delirium is by definition a direct physiological consequence of a general medical condition and is probably the most common presenting symptom of disease in old age. MATERIAL AND METHODS: Literature review based on search on PubMed and Medline up to 31 December 2001 and a summary of several doctoral theses and our own clinical experience. RESULTS AND INTERPRETATION: Several recent intervention studies have clearly shown that delirium can be prevented and treated. Successful intervention programmes have been multifactorial and interdisciplinary, including assessment and treatment of underlying causes as well as prevention and treatment of factors endangering cerebral metabolism. In particular, cerebral hypoxemia caused by i.e. sleep-apnoea syndrome, anaemia, hypotension, pulmonary diseases, and heart failure is often easily prevented and treated. Excellent nursing care seems to be a prerequisite for successful prevention and treatment of delirium. Acceptable scientific evidence for pharmacological treatment is still lacking; it is sometimes necessary but should be used with caution. If sedation is acceptable, clomethiazole is the drug of choice but if the delirium is complicated by frightening hallucinations and agitation, haloperidol or risperidone can be used but only for short periods. Cholinesterase inhibitors are probably a better choice, though randomised treatment studies are still lacking.