The feasibility of masks and face shields designed by 3D printing makers; some considerations of their use against the COVID-19.

The use of mask and face shield has been established as one of the main preventive measures for the control of COVID 19 spread. In Mexico, as well as in other regions of the world, 3D printing has been employed for the design and production of masks and face shields as personal protective equipment (PPE). These models have been fabricated mainly by the makers, industries, and university communities; therefore, it is necessary to analyze the feasibility of the 3D printed PPE to understand its advantages and limitations. In this work, some characteristics of masks and face shields fabricated by additive manufacturing were studied to explore their viability as protection against flow fluids similar to human sneeze. In the present paper, the PPE was designed, and 3D printed utilizing three types of polylactic acid (PLA) as base material. The morphology and the surface elemental analyses of sectioned samples were analyzed by scanning electron microscopy (SEM) and energy dispersion x-ray spectroscopy (EDS). Showing spacing between printed layers, porous areas, and dispersed copper particles. On the other hand, a computational fluid dynamics (CFD) simulation was carried out, the results demonstrated the importance of using PPE for protection of a possible exposure to a "contaminated" aerosol and human sneeze. Based on the abovementioned results, it is possible to consider the commercial PLA as suitable material for the manufacturing of PPE due to its capability to be disinfected employing isopropanol, ethanol, or commercial disinfectants.

Analysis of outcomes of emergency general and gastrointestinal surgery during the COVID-19 pandemic.

BACKGROUND: Few surgical studies have provided adjusted comparative postoperative outcome data among contemporary patients with and without COVID-19 infection and patients treated before the pandemic. The aim of this study was to determine the impact of performing emergency surgery in patients with concomitant COVID-19 infection. METHODS: Patients who underwent emergency general and gastrointestinal surgery from March to June 2020, and from March to June 2019 in 25 Spanish hospitals were included in a retrospective study (COVID-CIR). The main outcome was 30-day mortality. Secondary outcomes included postoperative complications and failure to rescue (mortality among patients who developed complications). Propensity score-matched comparisons were performed between patients who were positive and those who were negative for COVID-19; and between COVID-19-negative cohorts before and during the pandemic. RESULTS: Some 5307 patients were included in the study (183 COVID-19-positive and 2132 COVID-19-negative during pandemic; 2992 treated before pandemic). During the pandemic, patients with COVID-19 infection had greater 30-day mortality than those without (12.6 versus 4.6 per cent), but this difference was not statistically significant after propensity score matching (odds ratio (OR) 1.58, 95 per cent c.i. 0.88 to 2.74). Those positive for COVID-19 had more complications (41.5 versus 23.9 per cent; OR 1.61, 1.11 to 2.33) and a higher likelihood of failure to rescue (30.3 versus 19.3 per cent; OR 1.10, 0.57 to 2.12). Patients who were negative for COVID-19 during the pandemic had similar rates of 30-day mortality (4.6 versus 3.2 per cent; OR 1.35, 0.98 to 1.86) and complications (23.9 versus 25.2 per cent; OR 0.89, 0.77 to 1.02), but a greater likelihood of failure to rescue (19.3 versus 12.9 per cent; OR 1.56, 95 per cent 1.10 to 2.19) than prepandemic controls. CONCLUSION: Patients with COVID-19 infection undergoing emergency general and gastrointestinal surgery had worse postoperative outcomes than contemporary patients without COVID-19. COVID-19-negative patients operated on during the COVID-19 pandemic had a likelihood of greater failure-to-rescue than prepandemic controls.

Electromyographic activity of the jaw muscles and mandibular kinematics in young adults with theoretically ideal dental occlusion: Reference values.

BACKGROUND: A necessary step to use neuromuscular analysis as diagnostic tool is to establish normal reference values for the physiological range in a healthy population. Surface electromyographic (sEMG) activity of the jaw muscles and mandibular kinematics were measured in young adults with theoretically ideal dental occlusion to determine normal reference values during different tasks. Differences between the sexes were evaluated. MATERIAL AND METHODS: Forty young adults (20 men, 20 women; mean age 22.8 ± 3.9 years) with theoretically ideal dental occlusion were selected using very restrictive criteria. sEMG activity of the anterior temporalis (AT), posterior temporalis, masseter (MA), and suprahyoid muscles were evaluated in the rest position and during swallowing, mastication, and clenching. Mandibular kinematics in the rest position and during maximum excursions were assessed. Asymmetry, activity, and torque indices and MA/AT ratios were calculated. RESULTS: For all muscles, sEMG values were 1.01-3.57 µV at rest, 3.50-10.85 µV during swallowing, and 41.04-86.59 µV during mastication. During clenching, values were 230.08-243.55 µV for the AT and MA muscles. Mean total asymmetry, activity, and torque indices at rest were 20.34 %, -15.04 %, and 19.02 %, respectively; during clenching, these values were 6.14 %, -2.62 %, and 4.46 %. MA/AT ratios were near 1. Kinematic measurements during lateral excursion, protrusive and maximum opening were 7.54, 8.44, and 37.38 mm respectively; lateral mandibular shift was 1.41 mm; free way and lateral displacement at rest were 1.40 and 0.26 mm. Right MA activity during mastication and clenching was higher in men than women. CONCLUSIONS: Reference values for sEMG activity and mandibular kinematics were determined. Some muscular asymmetry and torque were observed.

[French survey on perioperative nutrition in cirrhotic adult patients waiting for liver transplantation]. / Enquête sur l'évaluation et la prise en charge nutritionnelle des patients adultes cirrhotiques candidats à une transplantation hépatique.

OBJECTIVE: The European Society for Clinical Nutrition and Metabolism (EPSEN) guidelines on nutrition for liver disease patients has been recently updated. The aim of our study was to evaluate perioperative nutrition in cirrhotic patients waiting for liver transplantation (LT). STUDY DESIGN: Prospective electronic survey. A standardized questionnaire was sent to the anaesthesiologist of the 18 French adult LT centers. The questionnaire had closed-ended questions to evaluate nutritional practices in cirrhotic patients waiting for a LT. RESULTS: The response rate was 100%. Nutritional status of the cirrhotic patients waiting for LT was assessed by anaesthesiologists (12 centres) and/or hepatologists (11 centres) and more rarely by nutrition physician, dietetics or liver surgeons. Body mass index (13 centres), weight loss (10 centres), albuminemia (10 centres) were the most frequent items used to assess the nutritional status. Before LT, preoperative oral intakes were administered in undernourished patients in only 55% of the cases. Postoperatively, nutritional support was administered between day 1 and 3 after LT. CONCLUSION: Perioperative nutritional practices in cirrhotic patients waiting for LT are heterogeneous between centers, especially about nutrition assessment. Most of the centres did not follow the actual guidelines.

Condroma intracraneal: un caso de muerte súbita / Intracranial chondroma and sudden death: a case report

Las muertes súbitas por tumores intracraneales primarios no diagnosticados en vida son excepcionales. Presentamos un caso de muerte súbita en un adulto joven, sin antecedentes relevantes de interés, en el que la autopsia evidencia como causa de muerte un condroma intracraneal. De acuerdo a la revisión bibliográfica realizada en todos los casos publicados se había efectuado un diagnóstico en vida, por lo que es excepcional que este tumor debute con una muerte súbita. El condroma intracraneal es un tumor benigno, poco frecuente y con características histopatológicas y radiológicas bien definidas. El tratamiento de elección es la resección completa y el pronóstico a largo plazo es bueno. Este caso demuestra que a todas las personas jóvenes que fallecen de forma súbita e inesperada se les debería practicar una necropsia a fin de agotar todos los medios diagnósticos para averiguar la causa de la muerte(AU)

Sudden deaths due to primary intracranial tumours undiagnosed during life are rare. We present a case of sudden death in a young adult with no clinical history of interest. The forensic autopsy discovered that the cause of death was an intracranial chondroma. According to the literature, intracranial chondromas are usually diagnosed in life, so the onset of this tumour as sudden death is exceptional. Intracranial chondroma is a rare benign tumour. Histopathological and radiological characteristics are well defined. The treatment of choice is complete resection, and the long-term prognosis is good. This case shows that it would be convenient to perform an autopsy of all unexpected sudden deaths in young people, in order to determine the cause of death(AU)

Clinical assessment of external rotation for the diagnosis of anterior shoulder hyperlaxity.

The aim of this study was to evaluate two methods of clinical assessment for external rotation of the shoulder to optimise the diagnosis of hyperlaxity in patients being selected for surgery for stabilisation of chronic anterior instability. External rotation was evaluated in 70 healthy student volunteers by two examiners (intertester study) using two methods of assessment at 15-day intervals (intratester study). The first method used was the protocol described for the Instability Severity Index Score (ISIS). In this case, the subject was evaluated in the sitting position, bilaterally with passive range of motion movements. The shoulder was considered hyperlax if ER1 was greater than 85°. With the second, so-called "elbow on the table" (EOT) method, the subject was evaluated in the decubitus dorsal position, unilaterally with passive range of motion. The subject was considered to be hyperlax if ER1 was greater than 90°. Kappa values for intra- and intertester agreement with the ISIS method were average, while they were satisfactory with the intraclass coefficient (ICC). Kappa values for inter- and intratester agreement with the EOT method were average and good, respectively. This tendency was confirmed by the ICC which went from good to excellent for the two examiners in both series of measurements using the EOT method, showing better reproducibility with this method. Our study confirms that the most reproducible method for assessing external rotation is obtained by unilateral assessment of the patient in the decubitus dorsal position, with passive range of motion. An ER1 of 90° is the necessary threshold for hyperlaxity because of elbow retropulsion with this method, which provides immediate and visual evaluation and eliminates the necessity of goniometry.

[Teaching and perception of urology by medical students at the end of the second cycle: an appraisal]. / Enseignement et perception de l'urologie à la fin du deuxième cycle des études médicales: état des lieux.

OBJECTIVES: Our purpose was to determine how the medical students from the second cycle perceived urology and what their learning methods were. MATERIAL AND METHODS: An e-questionnaire was sent to 1600 students in 16 teaching faculties during the last year of their second cycle. RESULTS: Overall, we obtained 590 answers (36.8%). In our population, 70.2% of the students were women. Of them, 24.1% had been already enrolled in an academic urology unit. Urology was defined as a medical, surgical and medico-surgical discipline by 3.7%, 37.8% and 58% of the students, respectively. Urology was considered as very important, important, not very important and not important at all by 5.1%, 54.4%, 37.5% and 2.4% of the students. The teaching methods used to learn urology were duplicated-notes for ENC preparation (45.3%), conferences for ENC (French national ranking exam) preparation (43.7%), courses of the national urology college (38.6%) and courses of the faculty (32%). The best mastered items were lithiasis disease (86.3%), voiding dysfunction (76.3%) and urological cancers (56.7%). On the contrary, only 34.7% and 28% considered their knowledge sufficient on the erectile dysfunctions and on renal transplantation. Lastly, 7.3% intended to become urologists. Having a work experience in a urology unit was significantly associated to the feeling of being prepared to become an intern (p<0.001) and to the project of becoming a urologist (p<0.001). CONCLUSION: Urology was considered like an important discipline by half of the students at the end of the second cycle even though it is under-represented in the national teaching programme for ENC. A third of the students used courses from the faculty to learn urology and a quarter of them had a work experience in a urology unit during their second cycle.

[Evidence-based medicine and French medical students: an appraisal]. / Evidence-based medicine et étudiants en médecine français : état des lieux.

INTRODUCTION: Nowadays, evidence-based medicine (EBM) is essential to learn and to practice medicine. The aim of the current study was to investigate the baseline level of knowledge of French students regarding EBM. MATERIALS AND METHODS: Between April and May2008, a questionnaire was sent by e-mail to 900students in their last year of medical study. RESULTS: On 327 answers, 297 (91%), 94 (29%) and 85 (26%) students declared they read, write and speak medical English. Ninety (28%) read an article of a French medical review once a month and 43 (13%) read an article of an international medical review once a month. Three hundred and eleven (95%) knew the bases of medical research on the Internet and 219 (67%) used them. Twenty-four (7%) had already participated in a editorial staff of a medical article, 7 (2%) had been co-authors. Two hundred and seventy-two (83%) had made an oral presentation during a medical staff and 3 (1%) during a congress. Finally, 237 (73%) understood the interest of the critical analysis of an article at the ECN and 70 (21%) thought they were prepared. CONCLUSION: The incapacity of learning EBM is one of the limits of the French medical training system. The introduction of the reading critical of an article at the ECN is the concrete beginning of an answer to this problem.

Long-term efficacy of mupirocin in the prevention of infections with meticillin-resistant Staphylococcus aureus in a gastroenterology unit.

The long-term efficacy (55 months) of eradication of nasal carriage of meticillin-resistant Staphylococcus aureus (MRSA) by mupirocin was assessed for MRSA infections in a gastroenterology unit receiving patients for long hospital stays. In total, 2242 patients were included in the study; 92% had been hospitalized in another hospital before admission to the study department, 64% had chronic liver diseases (LD), 25% had miscellaneous medical conditions and 11% were admitted following gastroenterological surgery. Three consecutive periods were considered in the analysis. Nasal carriage at admission was similar in all three periods (10.9 vs 7.5 vs 8.6% in Periods 1, 2 and 3, respectively), while acquired nasal carriage decreased in the whole population (14.3 vs 16.2 vs 10.2% in Periods 1, 2 and 3, respectively, P=0.006) and in LD patients (15.8 vs 18.7 vs 11.9% in Periods 1, 2 and 3, respectively, P=0.018). The incidence of MRSA infections (N per total number of hospitalization-days) was 1.41 per 1000 in the year before initiation of eradication, 1.40 in Period 1, 0.74 in Period 2 and 0.59 in Period 3 (P=0.022). The incidence of MRSA infections among patients was 7.0% in Period 1, 3.7% in Period 2 and 3.1% in Period 3 in LD patients (P=0.0062). The corresponding figures were 5.5, 3.0 and 2.4% for the whole population (P=0.0024). The mortality caused by MRSA was 0.31, 0.19 and 0.13% (P=0.035) in Periods 1, 2 and 3, respectively. The numbers of resistant strains among those acquired during hospitalization were 12 in Period 1, four in Period 2 and six in Period 3. Long-term intranasal mupirocin treatment in MRSA carrier patients with long hospital stay is associated with a decrease in acquired carriage and MRSA infections, while resistance of the strains to mupirocin does not increase provided that colonized patients are only treated once.

Increased risk of alteration of nutritional status in hospitalized elderly patients with advanced cancer.

Malnutrition is common in patients with advanced cancer and is associated with worse prognosis. The aim of this study was to follow-up the nutritional status of elderly patients with advanced cancer in comparison with that of younger ones, in the course of hospitalization. Eighty-eight (44 males and 44 females) patients with advanced cancer entered the study. Two groups were defined according to age : superior 70 y (n = 45) and < 70 y (n = 43). Nutritional status by means of anthropometric variables and daily intake were assessed on Day 0, Day 30 and Day 60. A blood sample was collected on Day 0 for determination of serum proteins. The two groups of patients did not differ in terms of anthropometry and biological variables on admission to our department ; only bicipital skinfold thickness and energy intake were lower in the elderly patients. After one month hospitalization, tricipital skinfold thickness and fat mass decreased in these patients. After two months, mid-arm circumference also decreased. Unlike the older group, the younger patients increased their daily energy and protein intakes. During hospitalization, older persons with advanced cancer cannot improve their energy intake and therefore, are at particular risk of aggravating their nutritional status.

Value of body mass index in the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters.

BACKGROUND & AIMS: We have estimated the prevalence of severe malnutrition in groups of patients hospitalized for different medical causes and assessed the sensitivity of BMI in the diagnosis of severe malnutrition. DESIGN: A prospective study enrolled 1052 patients: 396 patients with liver cirrhosis including 165 non-ascitic patients (NAP), 124 patients with mild ascites (MAP), 107 patients with tense ascites (TAP), 251 patients after cardiac surgery (SCP), 81 patients with cardiac diseases (MCP), 85 patients with stroke (SP), 36 patients with degenerative neurological diseases (DNP), 68 patients after surgery of a hip fracture (HFP), 91 patients with palliative care for cancer (CP) and 44 elderly patients with medical affections (EP). BMI, mid-arm muscular circumference (MAMC) and triceps skinfold thickness (TST) were measured within 48 h after admission. Patients with MAMC and TST below the 5th percentile of a reference population when aged < or = 74 or the 10th percentile when aged > or = 75 were defined as severely malnourished. Sensitivity of BMI < 20 to detect malnutrition was assessed. RESULTS: The prevalence of severe malnutrition was the highest in TAP (39.1%) HFP (25.6%) and MAP (24.3%) and the lowest in SCP (4%), SP (4.8%), DNP (5.7%) and MCP (7.4%) (P < 10(-4)). In multivariate analysis, low TST was associated with female gender (P < 10(-4)) mild and tense ascites (P = 0.038, P = 0.0004), low MAMC with male gender (P < 10(-4)), low BMI with female gender (P = 0.0082), hip fracture (P = 0.0407) and cancer (P = 0.0059). The sensitivity of BMI to detect severe malnutrition was the highest in HFP, CP and EP (100%, 80% and 100% respectively) and the lowest in TAP, MCP and SP (40%, 33.3% and 50% respectively). After exclusion of TAP, sensitivity of BMI to detect malnutrition correlated significantly with the coefficient of correlation between MAMC and TST observed in each group (r = 0.821, P = 0.0066). CONCLUSION: Ascitic cirrhotic patients and elderly patients after surgery of hip fracture had the highest prevalence of severe malnutrition. BMI had the highest sensitivity when both TST and MAMC were damaged to the same extent. BMI < 20 has a high sensitivity in the diagnosis of severe malnutrition in elderly and cancer patients but not in cirrhotic patients with tense ascites, cardiovascular and neurological patients.

Protocolo de actuación forense ante la sospecha de meningitis bacteriana y shock séptico fulminante / Protocol for the forensic action with regard to the suspicion of bacterial meningitis and fulminant septicemia

Una importante tarea de las instituciones médico-legales es la colaboración con las autoridades sanitarias en la prevención de riesgos para la salud pública. Uno de ellos es la infección meningocócica, que puede cursar rápidamente y con evolución fatal, causando muerte súbita. Neisseria meningitidis es la principal causa de meningitis bacteriana y septicemia en niños y adultos jóvenes. Su temprana detección es de extrema urgencia, ya que permite el adecuado tratamiento de los contactos. El rápido desarrollo de estas infecciones imposibilita en ocasiones el diagnóstico antemortem, resultando imprescindible el diagnóstico forense. Aunque los hallazgos postmortem suelen ser los del síndrome de Waterhouse-Friderichsen, estos, a veces, pueden pasar desapercibidos, o estar causados por otras bacterias. Todo ello hace necesario un diagnóstico microbiológico forense. Este artículo presenta un protocolo forense de actuación ante la sospecha de meningitis bacteriana y shock séptico fulminante. La toma de muestras para microbiología debe ser aséptica e incluir sangre, suero, LCR, líquido pleural, tejidos en fresco y orina. Estas muestras pueden remitirse al Instituto Nacional de Toxicología y Ciencias Forenses, donde se realizarán análisis específicos, que incluyen un screening antigénico y un diagnóstico de confirmación mediante PCR a tiempo real que identifica meningococo y su serogrupo. Los resultados de estas técnicas son informados 3 horas tras el inicio del análisis. También se realiza el cultivo bacteriano y PCR adicionales para detectar otras bacterias difíciles de aislar postmortem. La colaboración entre las distintas instituciones médico-legales y entre estas y las autoridades sanitarias es esencial para el adecuado manejo de estas graves infecciones (AU)

One of the main duties of medical-legal institutions is to collaborate with authorities to recognise and prevent risks to public health. One such risk is meningoceal infection, wich can progress rapidly and fataly, causing sudden death. In such cases, it is urgent to identify "Neisseria meningitidis" urgently in order to assure the appropiate treatment of people who have come into contact. This agent is a leading cause of bacterial meningitis and septicemia in children and young adults. Due to the rapid development of such infections, ante-mortem cultures sometimes are not taken, making the forensic diagnosis essential. Although post-mortem findings are often typical of the Waterhouse-Friderichsen syndrome, they may sometimes be overlooked or caused by other organisms. For these reasons, a microbiological forensic diagnosis is crucial. This article presents a forensic procedure to diagnose the etiology of fulminant bacterial meningitis or septic shock. The aseptic sampling should include blood, sera, LCR, pleural effusions, urine and fresh tissues. These samples can be submitted to the Instituto Nacional de Toxicología y Ciencias Forenses for their early analyses. Antigenic tests are performed as screening techniques, and real-time PCR assays are also done to detect meningococcus and identify its serogroup. The results of these analyses are reported in 3 hours. Bacterial cultures are also performed. Additional PCR may be performed to diagnose other fragile bacteria that are difficult to recover post-mortem. The collaboration within all legal institutions and between those and health authorities is essential to best deal with this issue (AU)

A clinical trial of mupirocin in the eradication of methicillin-resistant Staphylococcus aureus nasal carriage in a digestive disease unit.

We assessed the incidence of nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) on admission, the rate of acquisition during the hospital stay and the relationship with subsequent infection in a digestive disease unit. The efficacy of a program of nasal carriage eradication with mupirocin was evaluated simultaneously. Over one year 484 patients were studied prospectively on admission for nasal and stool carriage of MRSA, then every week for nasal carriage. Nearly 70% (68.8%) of patients had chronic liver diseases. Nasal carriers were assigned to a five-day course of intranasal mupirocin ointment. One hundred and seventeen (24.2%) patients were MRSA positive, 57 (11.8%) of which were carriers on admission and 60 (12.4%) acquired carriage. Of these, 86 were treated with mupirocin with a success rate of 98.8% and 25.9% of them recolonized. Fourteen patients were retreated, to allow eradication in 71.4% of cases. Seventy percent of these became carriers again. One high-level mupirocin-resistant strain was isolated before treatment and seven during or after treatment. Hospital stay and stool carriage were independently associated with reacquisition (P = 0.0105 and P = 0.0462, respectively). Molecular analysis showed identity between the strains isolated from infection samples and from nasal swabs during the same week. For every patient who became recolonized, nasal strains isolated before and after eradication were the same in 70% of cases. Mortality during hospital stay was independently associated with age (P = 0.0081), MRSA nasal carriage (P = 0.02631), MRSA infection (P < 0.0001) and liver disease (P = 0.0017). This study did not show a change in the prevalence rate of infection in the unit during treatment with mupirocin. This treatment should only be attempted once due to the risk of emergence of high-level resistant strains.

Serum leptin levels in alcoholic liver cirrhosis: relationship with gender, nutritional status, liver function and energy metabolism.

OBJECTIVE: To determine serum leptin levels in alcoholic liver cirrhosis and the relationship with gender, nutritional status, liver function, energy metabolism, inflammatory state and refeeding. SUBJECTS: Thirty-seven hospitalized alcoholic cirrhotic patients (M/F: 24/13), 27 hospitalized patients at risk of malnutrition but with normal liver function (M/F: 15/12) as control patients, and 31 healthy control subjects (M/F: 17/14) participated. DESIGN: Liver function was assessed from Child-Pugh classification; anthropometric parameters and resting energy expenditure (REE) were measured; caloric intake was evaluated over 5 days; and serum leptin and insulin were assayed. The same protocol was performed after 1 month refeeding in 22 patients. Healthy subjects were studied as controls for anthropometric parameters and serum leptin levels. RESULTS: Serum leptin levels were higher in male cirrhotic patients than in the other two male groups (P=0.0079) and in the same range in the female groups. They were higher in female than in male subjects in the three groups. In female cirrhotic patients, logarithmically transformed serum leptin levels correlated significantly with fat mass (P=0.0043), insulin levels (P=0.0072), REE (P=0.0133), bilirubin levels (P<0.0001), prothrombin time (P=0.0003) and Pugh score (P=0.0266) in simple regression analysis and with insulin levels (P=0.0137), but not with fat mass (P=0.0761), Pugh score (P=0.4472) and REE (P=0.4576) in multiple regression analysis. In the male cirrhotic and control patients, log (leptin) levels correlated with CRP (C reactive protein) (r=0.365, P=0.0223). Log (leptin) levels did not correlate with caloric intake in any of the groups. Leptin levels (P<0.05) and fat mass (P<0.02) increased with refeeding while liver function improved (P<0.01). CONCLUSION: There is a gender difference in regulation of serum leptin level in alcoholic liver cirrhosis. Insulin level is the best determinant of leptin level in female patients while inflammatory state related to alcoholic hepatitis seems to have a greater influence in male patients. Although leptin levels positively correlated with REE in female patients, there is no evidence that leptin reduces caloric intake and fat stores in these patients.

[Nutritional status assessment in 57 hospitalized aged patients: impact of the causal disease]. / Evaluation de l'état nutritionnel de 57 malades âgés hospitalisés: influence de la pathologie causale.

PURPOSE: To study the nutritional status in elderly patients hospitalized for rehabilitation and to compare it among patients with hip fracture and those with medical care. METHODS: Patients were nutritionally assessed upon admission (d0) to our unit by measurement of anthropometric, biological parameters and dietary intake. Thirty-seven patients were operated for hip fracture (group I) and 21 were hospitalised for medical disease (group II). Nutritional status was compared in the two groups on d0 and was evaluated after one month (d30) in the operated group. RESULTS: No significant difference could be observed for any anthropometric or biologic (albumin, transthyretin and transferrin) in the two groups. Daily food intake related to body weight was much the same in both groups (31 kcal/kg). C-reactive protein and orosomucoid levels were above the reference range in both groups. Hip fracture operated patients had higher orosomucoid than non-operated ones (1.50 +/- 0.4 versus 1.14 +/- 0.4 g/L; P = 0.002). One-month follow-up of nutritional status performed in 31 operated patients showed a significant decrease in TST and MAC (respectively p = 0.02 and p = 0.007) and in orosomucoid (p = 0.003) although daily food intake increased. CONCLUSION: Twenty-eight percent of patients were undernourished upon admission in the unit. A moderate inflammatory state still remained in all our patients, particularly in those who had undergone surgery. This inflammatory state persisted two months after surgery.

Epidemiology of hospital-acquired infections in cirrhotic patients: effect of carriage of methicillin-resistant Staphylococcus aureus and influence of previous antibiotic therapy and norfloxacin prophylaxis.

We assessed the prevalence of carriage of methicillin-resistant Staphylococcus aureus (MRSA) in anterior nares and stools, and of third-generation cephalosporin resistant enterobacteriaceae and non-fermenting gram-negative bacilli (RE/RNF) in stools of 748 hospitalized long-stay cirrhotic patients. We also evaluated the consequences of carriage on the epidemiology of hospital-acquired spontaneous bacterial peritonitis, bacteraemia and urinary tract infection (UTI) in these patients. The prevalence of carriage of MRSA and RE/RNF was 16.7% and 14.7% respectively. Whereas RE/RNF carriage did not lead to an increased risk of infection due to RE/RNF, the overall risk of infections caused by MRSA was more than tenfold higher in MRSA carriers. MRSA and RE/RNF carriers had received prior antibiotic therapy to a greater extent than non-carriers (P < 0.001) and MRSA carriers had received prior norfloxacin prophylaxis to a greater extent than the two other groups (P < 0.02). The mortality rate during hospital stay was higher in MRSA and RE/RNF carriers than in non-carriers (P < 0.001). Pugh score (P < 0.0001), age (P < 0.0001), MRSA carriage (P = 0.0018) and bacteraemia (P = 0.0017) were associated independently with mortality. MRSA carriage in hospitalized cirrhotic patients leads to the emergence of infections due to this strain, mainly SBP and bacteraemia. Prior antibiotic therapy and norfloxacin prophylaxis increase the risk of carriage of MRSA.

Serum levels of insulin-like growth factor-1 in the three months following surgery for a hip fracture in elderly: relationship with nutritional status and inflammatory reaction.

BACKGROUND AND AIMS: Serum IGF-1 level declines with advancing age and is a reliable index of protein-energy undernutrition in elderly patients in a metabolically stable condition. We have examined the value of IGF-1 as an indicator of malnutrition in elderly patients during recovery within 1 month after surgery for a hip fracture and we have studied the relationship between changes in IGF-1 levels, nutritional status and inflammatory reaction during 2 month follow up. STUDY DESIGN: Forty elderly patients (mean age 84.0+/-1.9) were nutritionally assessed upon admission to our rehabilitation unit (D0) then monthly (D30-D60) by measurement of anthropometric and biological parameters. Two groups of patients were defined on the basis of mid-arm circumference (MAC) and tricipital skinfold thickness (TST) measurement at D0: group 1, undernourished (n=13) and group 2, normally nourished (n=27). Changes in anthropometric and biological parameters during the study were compared between these two groups of patients. RESULTS: IGF-1 level was significantly lower in group 1 (79.5+/-9.1 vs 108+/-8.6 ng/ml, P<0.05) while usual serum protein levels were in the same range in the two groups. Orosomucoid level significantly decreased during 2 month follow-up in group 2 (P<0.01), CRP level decreased but not significantly. TST and MAC decreased in group 2 (respectively P<0.02 and P<0.05) while anthropometric parameters tended to slightly increase in group 1 in relation with an increase in caloric intake (P<0.05). IGF-1 level increased significantly during the study in group 2 (P<0.05) and was significantly lower in patients with complications occurring between D0 and D30 in comparison with patients without complications (respectively P<0.05 at D0, P<0.02 at D30). IGF-1 level correlated with body mass index, MAC, TST, muscle midarm circumference, albumin and transthyretin levels. Changes in IGF-1 levels positively correlated with those in transthyretin levels and negatively with those in orosomucoid levels. CONCLUSION: IGF-1 level seems a reliable index of protein-energy under-nutrition in elderly patients in the recovery period after surgery for a hip fracture. This marker is influenced by the inflammatory reaction. Decline of inflammatory reaction, rather than change in nutritional status, is responsible for the variation in IGF-1 level during a 2 month follow-up.

Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up.

A 2-month follow-up of nutritional status was performed in forty elderly patients with recent hip fracture. Patients were nutritionally assessed on admission to our rehabilitation unit (day 0), then monthly (day 30, day 60) by measurement of resting energy expenditure (REE), anthropometric, impedance and biological variables. Patients were defined as undernourished (n 13) or normally nourished (n 27) on the basis of mid-arm circumference (MAC) and triceps skinfold thickness (TST) measurements. Seven patients recovered a walking autonomy and were discharged from the hospital before day 30 (group I) whereas thirteen patients were discharged after day 30 (group II); twenty patients remained in the study at day 60 (group III). MAC and TST decreased in normally nourished patients from group III throughout the study whereas they did not change in group II or in undernourished patients from group III. REE values in relation to fat-free mass were increased compared with normal values and were similar in the three groups on day 0; they did not change during the study. Daily energy intake in relation to body weight was higher in group I and increased in group II and in undernourished patients from group III throughout the study. In contrast, it was below the recommended value at day 0 and it did not significantly improve in normally nourished patients from group III. Serum albumin, transthyretin and transferrin levels on day 0 were below reference intervals in the three groups. Albumin levels increased in group III throughout the study. Inflammatory proteins decreased in groups II and III, with C-reactive protein levels returning to normal values in group II by day 30 and in group III at day 60, while orosomucoid levels did not become completely normal over this period. Our findings indicate no improvement in nutritional status in undernourished patients after surgery for recent hip fracture, despite an adequate energy intake. An insufficient spontaneous energy intake for normally nourished patients was associated with a delayed favourable outcome resulting in a prolonged duration of hospitalization. A hypermetabolic state persisted during the 3 months after surgery.