High consumption foods and their influence on energy and protein intake in institutionalized older adults.

BACKGROUND: The elderly, and especially those attending nursing homes, are at great risk from certain nutritional deficiencies. OBJECTIVE: The aim of this study was to determine which food groups present the highest rates of consumption among the institutionalized elderly and study the energy density of each food group and the number of calories and amount of protein in the total diet of each resident. DESIGN: This was a multicentre observational study of a sample of the institutionalized population over the age of 65. The sample of patients was drawn from four Spanish nursing homes (Santa Coloma Gramanet, Barcelona, Madrid and Bilbao). Our final sample comprised a total of 62 individuals, of whom 22 were men and 40 women, aged between 68 and 96 years. METHODS: Dietary data were collected using the double weight method for each main meal (breakfast, lunch, afternoon snack and dinner), including food type, the quantity of food served and the amount of plate waste for each of the main meals served during 21 days. STATISTICAL ANALYSES: The characteristics of the study population were compared by Student's t-test and χ2 test. The results are expressed in terms of their median values and the interquartile range. To analyse the overall differences between sites, gender and food groups we used Kruskall-Wallis test combined with the Mann-Whitney U-test with Bonferroni correction for multiple comparisons. RESULTS: The food group that was served most was milk products (376.25 g/day). A large amount of potatoes were also served (109.64 g/day) as were sweets and pastries (62.14 g/day). The daily serving of fruit (138.34 g/day) and vegetables (239.47 g/day) was equivalent to no more than that of a daily ration in each case. Milk was the food group with the highest consumption (311 g/day). Most of the energy was provided by groups with a higher energy density like as fats and sauces, sweets and pastries and bread. The mean protein consumption was 82,6 g/day (Table 5) and no significant differences were recorded in this consumption between men and women. CONCLUSIONS: We conclude that there is a need to improve the residents' energy intake and to redistribute their energy and protein intake among the various food groups. An alternative to increasing food portions so as to improve energy intake might involve enriching certain food types.

Lamotrigine and epilepsy in the elderly: observational study of low-dose monotherapy.

A one-year prospective, observational study was conducted in 222 elderly patients (>65 years old) with epilepsy. Patients received 25 mg/day lamotrigine for the first 15 days. The dose was then increased to 50 mg/day; further increases were allowed if necessary. Vascular epilepsy was the most frequent diagnosis (56% of patients), and concomitant medication was required by 75% of patients. The mean dose was 72.17 mg/day in the 132 patients who completed the study; the initial dose of 50 mg/day was maintained in 52% of these patients. There was a marked reduction in the number of seizures with 89% of the patients who completed the study continuing to be seizure-free after 1 year. Tolerability was generally good with 15 adverse events in nine patients. Only two patients developed a rash. In conclusion, low-dose lamotrigine is an effective and well tolerated therapy for the control of epilepsy in elderly patients.

Factores pronósticos asociados al control médico en pacientes con evidencia radiológica de esclerosis mesial temporal / Prognostic factor for medical control for seizures in patients with radiologic evidence for mesial temporal lobe sclerosis

Introducción. El síndrome de esclerosis mesial temporal (EMT) asocia crisis febriles, crisis parciales complejas con una semiología característica, farmacorresistencia y atrofia de hipocampo o alteración de señal en secuencias de resonancia magnética. Aunque en la mayoría de los casos los pacientes van a presentar farmacorresistencia, algunos estudios previos han demostrado que la cuarta parte del total de los pacientes pueden controlarse con tratamiento médico. Objetivo. Valorar el pronóstico de control médico de los pacientes con EMT y determinar qué características clínicas pueden modificarlo. Pacientes y métodos. Se han analizado las características clínicas de 51 pacientes con crisis comiciales de origen temporal y con diagnóstico radiológico de EMT. Resultados. De los 51 pacientes, 17 (34 por ciento) eran hombres, 17 (34 por ciento) presentaban una EMT derecha; 30 (60 por ciento), EMT izquierda, y dos (4,3 por ciento), bilateral. 16 pacientes (34,8 por ciento) referían aura autonómica; 14 (27,5 por ciento), aura psíquica; cuatro (7,8 por ciento), disfasia; 13 (25,5 por ciento) no presentaban aura, mientras que en dos (3,9 por ciento) el aura era mixta: autonómica-psíquica. El aura presentaba asociación con la lateralidad de la lesión (p= 0,023) y con tener antecedentes de haber sufrido lesión cerebral durante la primera infancia (p= 0,011). Referente al control de las crisis, 15 pacientes (29,2 por ciento) estaban libres de crisis en los últimos 6 meses, y 36 (70,6 por ciento) presentaban crisis. Los factores que se asociaron al pronóstico de control médico fueron la edad de presentación de la primera crisis (p= 0,024) y la duración de la epilepsia (p= 0,018). Conclusiones. Hasta un 29 por ciento de los pacientes afectos de EMT puede controlarse médicamente; son factores de buen pronóstico un inicio tardío de la epilepsia, así como una corta duración de la enfermedad (AU)

Introduction. Patients with mesial temporal lobe sclerosis (MTS) usually have suffered a brain insult during early childhood, a febrile convulsion in most cases. Complex partial seizures start after a seizure free period of variable duration. These complex partial seizures have an stereotypic semiology. Often, these seizure are not controlled with medical therapy, previous studies shows a rate of control not superior of 30%. Aim. To know the prognosis for medical control of patients with MTS and to find related factors. Pastients and methods. The clinical characteristics of 51 patients with temporal lobe epilepsy and radiologic evidence of MTS (hippocampus atrophy or increased signal on T2 or FLAIR magnetic resonance sequences). Results. 51 patients, of them 17 (34%) were men. 17 (34%) presented right MTS, 30 (60%) left MTS and 2 (4.3%) bilateral MTS. 16 patients (34.8%) referred autonomic aura, 14 (27.5%) psychic aura, 4 (7.8%) dysphasia and 13 (25.5%) no aura, in 2 (3.9%) aura were mixed: autonomic-psychic. The aura was associated to the lesion laterality (p= 0.023) and to the reference of some antecedent of cerebral aggression during early childhood (p= 0.011). Concerning to the seizure control, 15 patients (29.2%) were seizure free in the last 6 month and 36 (70.6%) remaining uncontrolled. The associated factors to the medical control were the age of onset (p= 0.024) and the duration of the epilepsy (p= 0.018). Conclusions. Around 29% of patients with MTS can be controlled with medical therapy. Seizure control is related with later age of onset and short duration of the epilepsy (AU)

Gabapentin in late-onset poststroke seizures.

Stroke is a frequent cause of epileptic seizures (ES) in adults. The authors evaluated the long-term efficacy and tolerability of gabapentin (900 to 1,800 mg/day) in 71 patients with a first poststroke late ES during a mean follow-up time of 30 months. ES recurred in 18.3% of the patients and side effects were noted in 27 cases (38%), but only two (2.8%) required discontinuation or early withdrawal. Gabapentin monotherapy was useful and safe for late poststroke ES.

Assessment of dietary adequacy for an elderly population based on a Mediterranean model.

This study analysed whether at different energy levels, a varied diet based on Mediterranean Diet patterns would meet the RDIs for specific nutrients in a population > 65 y. Based on RDIs for elderly persons > 65 y for PRO, FAT CHO, phosphorus, calcium, magnesium, iron, zinc, vitamin C, B6, folate and fibre, menu models based on Mediterranean diet food patterns were calculated for the following calorie levels: 1400, 1500, 1600, 1700 and 1800 kcals. 15 menu variations for each calorie level were then created based on the previously calculated models. Utilising the Program for Alimentation and Nutrition (PAN) database, nutritional analysis was carried out for all menus and the mean nutrient values for a 2 week period were calculated for each calorie level. Intakes at all calorie levels provided adequate amounts of folate, phosphorus, iron and Vitamin B6. Intakes were low in all groups for Calcium, Zinc, Magnesium and Vitamin E, with the exception of the 1800 kcal level for Vitamin E. Results show that at low energy levels, meeting nutrient needs was difficult and that even at higher calorie intakes, contrary to what was expected, certain nutrients were found to be inadequate.

[Advances in the treatment of epilepsy: status epilepticus]. / Avances en el tratamiento de la epilepsia: estado de mal epiléptico.

OBJECTIVE: The complexity of the treatment of status epilepticus (SE) is due to the wide variety of forms of clinical presentation. In this review we wish to emphasize that satisfactory management of SE requires a system which takes account of the successive phases of the gravity of the electroclinical course of SE and the different types of SE according to the electroclinical semiology of the seizure. DEVELOPMENT: The concepts and classifications which, in current epileptology, are used in SE are mainly based on criteria developed at three international symposia: in Marseilles in 1962 and Santa Monica, California, in 1979 and 1997. Current knowledge permits distinction of different therapeutic periods depending on the chronology of each SE and to classify the SE according to the type of seizures, age of the patient and underlying pathology. CONCLUSIONS: The classifications described permit the standardization of treatment: preventive measure in high-risk patients; immediate and in situ treatment during the prodromal phase; three parallel lines of action--differential diagnosis, general measures and antiepileptic treatment--during the initial phase; measures in hospital emergencies and in the Intensive Care Unit when the SE is at a fully established phase; special measures, including induction of anaesthesia in the refractory phase; transition to long-term treatment, recovery of autonomy by the patient and long-term management in the phases following remission of the SE. The standardization proposed may perhaps serve as a basis for the future development of guidelines.

[Withdrawal of antiepileptic treatment in adults]. / Supresión del tratamiento antiepiléptico en la edad adulta.

INTRODUCTION: The withdrawal of antiepileptic treatment is a major challenge for the epileptologist who has to make a decision involving two risks, namely long term maintenance of drug treatment and recurrence of the seizures. OBJECTIVE: In our review we wish to systematize the process of decision-making and calculation of the possibilities of recurrence. DEVELOPMENT: First we review the factors to be considered when making a decision. This is complex since epileptics are a very heterogeneous group of patients. We emphasize the respect due to the patient who, in the end, is the one who assumes the risk involved. Then we consider the factors to be taken into account when calculating the individual's possibilities of having a recurrence and describe a theoretical outline of non-recurrence. Finally, we give details of the practical aspects of withdrawal of treatment. CONCLUSIONS: We emphasize that the current challenge in this field is to design a method of measuring risks to permit the prediction of probabilities of recurrence in individual patients. We quote examples of the classification and measurement of risks, and suggest that only by institutional measures--perhaps by organizations such as LECE--can further essential epidemiological studies, of great scientific interest in the long term, be carried out.

Supresión del tratamiento antiepiléptico en la edad adulta / Withdrawal of antiepileptic treatment in adults

Introducción. La supresión del tratamiento antiepiléptico supone un reto importante para el epileptólogo ya que debe tomar una decisión que se orienta entre dos riesgos, el del mantenimiento crónico de los fármacos y el de la recurrencia de crisis. Objetivo. Efectuamos una revisión para tratar de sistematizar el proceso de decisión y el cálculo de las posibilidades de recurrencia. Desarrollo. Revisamos, en primer lugar, los factores a tener en cuenta en el proceso de decisión, que debe su complejidad al hecho de que los epilépticos constituyen un conjunto de pacientes muy heterogéneo. Resaltamos el respeto a la autonomía del paciente que es quien, en última instancia, debe asumir el correspondiente riesgo. A continuación, repasamos los factores a tener en cuenta en un cálculo individualizado de posibilidades de recurrencia y tabulamos un perfil teórico de no recurrencia. Finalmente, detallamos los aspectos metodológicos de la retirada. Conclusiones. Destacamos que el reto actual, en este tema, es el de diseñar un método de cuantificación de riesgos que permita predecir, de manera individualizada, las probabilidades de recurrencia de un paciente concreto. Citamos algunos ejemplos de sistematización y cuantificación de riesgos, y sugerimos que sólo mediante una iniciativa institucional -quizás en el seno de entidades de las que la LECE es un ejemplo- podría cubrirse la necesidad de nuevos estudios epidemiológicos de indudable rentabilidad científica a largo plazo (AU)

[Monotherapy with gabapentin ++]. / Gabapentina en monoterapia.

INTRODUCTION AND OBJECTIVE: Gabapentin is an anti-epileptic drug approved in the USA in December 1993 as an additional treatment for patients with crises of partial onset. Recently it has been approved for use as monotherapy. We review the characteristics of this molecule as an anti-epileptic drug and the clinical trials which have permitted approval of the current indications. DEVELOPMENT: We review the particular difficulties of designing trials using monotherapy, both for ethical reasons (problems with the use of a placebo) and for technical reasons and those of interpretation (problems comparing two drugs with equivalent results) and analyze the trials in which attempts were made to overcome these difficulties. A trial designed to replace polytherapy in drug-resistant patients by monotherapy did not show conclusive results, although they were suggestive. A trial of patients admitted for pre-surgical studies permitted verification of the efficacy and safety of higher doses (3,600 mg/day) than those previously used (800-2,400 mg/day). Another trial, this time of newly diagnosed patients, permitted verification of the efficacy and safety of gabapentin used in different dosages. CONCLUSIONS: Gabapentin is effective when used as monotherapy. The dose recommended for the initial treatment of newly-diagnosed patients is 900 mg/day. It has a better safety profile than carbamazepine and is indicated in simple and complex partial crises with or without secondary generalization.

[The treatment of epilepsy. A therapeutic guide of the Catalan Society of Neurology]. / El tratamiento de las epilepsias. Guía terapéutica de la Societat Catalana de Neurologia.

INTRODUCTION: There have been major advances in the treatment of epilepsy over the past ten years, leading to marked changes in the way this illness is treated. However, the introduction of new drugs and new non-drug treatments have led to uncertainty in the medical profession with regard to their exact indications. For this reason, a group of neurologists of the Catalan Society of Neurology have drawn up guide-lines for the treatment of epilepsy. DEVELOPMENT: A panel of eight neurologists with a special interest in the diagnosis and treatment of epilepsy reviewed the literature to assess the data available regarding the treatment of epilepsy. A joint document was drawn up describing the basic rules for the use of antiepileptic drugs and the indications for other non-drug treatments. CONCLUSION: This document is an approved therapeutic guide to the treatment of epilepsy.

Lipoid proteinosis. A biochemical and ultrastructural investigation of two new cases.

Lipoid proteinosis is a rare autosomal recessive disease characterized by cutaneous and visceral lesions, in which large amounts of amorphous material are constantly found in stroma. Morphological and biochemical studies indicate abnormal collagen production, but little attention has been paid to the lipid component of lesions. Microscopic and ultrastructural studies of skin, with special emphasis on fibroblasts, vessels, nerve endings and eccrine sweat glands, were conducted in two patients with lipoid proteinosis. Biochemical studies were undertaken in cultured fibroblasts. Evidence of lysosomal storage in epithelial cells of eccrine sweat glands and in dermal histiocytes, very similar to that found in some metabolic disorders, particularly Farber disease, was found in both cases. Our findings suggest that two alterations might coexist in lipoid proteinosis, one characterized by impaired normal collagen production and the other related to a metabolic defect which may lead to accumulation of ceramide or more complex lipids.

[Usefulness of the EEG recording in the diagnosis of cyclosporin A-induced encephalopathy]. / Utilidad del registro EEG en al diagnóstico de encefalopatía asociada a ciclosporina A.

INTRODUCTION: Cyclosporine A is one of the immunosuppressors most frequently used to prevent transplant rejection. Neurotoxicity is one of the complications often associated with it. These complications include acute encephalopathy, lethargy, confusion state, tremor, headache, motor disorders, visual changes and epileptic crises amongst others, even when blood levels are at what are considered to be 'therapeutic' levels. CLINICAL CASES: We present the EEG anomalies found in 3 transplant patients (two liver transplants and on double lung transplant) to whom cyclosporin A had been given and who presented with status epilepticus. The EEG recordings showed paroxystic discharges of focal onset in the temporo-occipital areas. They were mainly correlated with the clinical findings of oculomotor and eyelid disorders. CONCLUSION: The topography of the neurophysiological findings supports--as do the other clinico-radiological findings--localization preferably to the posterior areas of cerebral dysfunction associated with cyclosporin A. Although the physiopathological origin of the encephalopathy of patients treated with cyclosporin A seems to correspond to multiple factors, we wish to point out the diagnostic usefulness of the identification of EEG changes localized to the temporo-occipital areas in the recognition of the neurotoxic syndrome in these patients.

[Diagnosis of seizures originating in the amygdala and the hippocampus]. / Diagnóstico de las crisis que se originan en la amígdala y en el hipocampo.

INTRODUCTION: Lesions in the hippocampus of some epileptic patients were first described one hundred and seventy years ago. Since then our knowledge of the relationship between epileptic seizures and temporal lobe lesions has greatly improved. DEVELOPMENT: The aim of this paper is to systematize the symptomatology of the hippocampus and amygdala seizures. These seizures may have a great number of different clinical features: special 'loss' or 'impairment of consciousness', epileptic automatisms and autonomic changes. Moreover, at the beginning of seizures some patients have reported experiences having subjective qualities similar to those experienced in everyday life. P Gloor named them 'experiential phenomena' and subdivided them into affective (eg: fear), perceptual (eg: visual hallucinations) and mnemonic (eg: 'déjà vu' illusion). CONCLUSION: It is very important to know the contribution of the hippocampus and the amygdala to the symptomatology of temporal lobe seizures due to the progress of MRI diagnostic possibilities that are improving the surgical outcome.

[Treatment of status epilepticus]. / Tratamiento de los estados epilépticos.

The management of status epilepticus (SE) is very complex due to the variability of its clinical features. This paper aims to achieve an schematic basis for a consensus in the treatment of these patients. Thus we need the clinical forms of SE grouped according to the differences in treatment. We also need to divided the development of every type of SE into stages in order to adjust the correct application of general measures and antiepileptic drugs. In patients prone to suffering recurrent seizures it is important to prevent risk factors. We can sometimes identify a premonitory phase during which the clinical deterioration presages SE; in these cases immediate treatment at home can prevent the evolution into true SE. Once SE has developed up to stage of early SE or stablished SE, the treatment must be carried out in emergency department. If seizures have not responded, the stage of refractory SE is reached and Intensive Care Unit facilities are mandatory. We devote special attention to conic-clonic SE but the other clinical forms of SE are categorized according to the differences in treatment.

Validation of different techniques for the diagnosis of ventilator-associated pneumonia. Comparison with immediate postmortem pulmonary biopsy.

To assess the accuracy of clinical parameters for the diagnosis of ventilator-associated (VA) pneumonia, as well as the diagnostic value of several invasive techniques, such as protected specimen brush (PSB), bronchoalveolar lavage (BAL), fiberoptic bronchial aspirates (FBAS), and percutaneous lung needle aspiration (PLNA), we compared the results of these techniques with the histopathology of immediate postmortem pulmonary biopsies, considered the "gold standard" reference test. We studied 30 mechanically ventilated patients (age 52 +/- 21 yr; mechanical ventilation period 9 +/- 7 days) who died in an intensive care unit. All patients received prior antibiotic treatment. The following procedures were performed immediately after death: bilateral PSB, BAL, FBAS, and PLNA, as well as bilateral minithoracotomies to obtain pulmonary biopsies as close as possible to the area sampled with the other techniques. According to the histopathology 18 patients had pneumonia and 12 did not. The presence of fever (sensitivity 55%, specificity 58%), purulent secretions (sensitivity 83%, specificity 33%), and chest radiograph infiltrates (sensitivity 78%, specificity 42%) could not differentiate in all instances presence from absence of pneumonia. Quantitative bacterial cultures of lung biopsies using 10(3) cfu/g as a cutoff point had low sensitivity (40%) and low specificity (45%) and could not differentiate the histologic absence or presence of pneumonia. Considering the histopathology of pulmonary biopsies as a gold standard, we found the following sensitivities for PSB, BAL, FBAS, and PLNA: 36, 50, 44, and 25%. The specificities were 50, 45, 48, and 79%, respectively. The sensitivities and specificities of different invasive techniques are much lower than those reported in clinical studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Value of fiberoptic bronchoscopy and angiography for diagnosis of the bleeding site in hemoptysis.

We evaluated 36 patients during active hemoptysis and compared the diagnostic yield of different procedures. Twenty-seven patients (75%) had one or more previous episodes of hemoptysis, most of which were not massive. Fiberoptic bronchoscopy was performed in 25 patients, and the bleeding site was identified in 17 (68%). The likelihood of localizing the bleeding site was significantly higher with early versus delayed fiberoptic bronchoscopy (91% versus 50%). Bronchial arteriography was performed in all 36 patients; positive arteriographies were observed in 20 cases (55.5%). Arteriography was positive in only 2 of the 8 cases in which fiberoptic bronchoscopy did not localize the site of bleeding. Bronchial artery embolization was successfully performed in 10 patients. However, the bleeding recurred within the first week after embolization in 2 patients, and 1 of them died.