Severity of pain is associated with insufficient energy coverage in hospitalised patients: A cross-sectional study.

BACKGROUND & AIMS: The severity of pain is routinely assessed in hospitalised patients but the impact of pain and pain control on energy coverage has been poorly studied. This One-day cross-sectional observational study assessed the association between severity of pain and coverage of energy needs in hospitalised patients. METHODS: Foods provided and consumed were assessed on one day by dedicated dieticians for unselected hospitalised patients receiving three meals per day. Severity of pain was evaluated by a visual analogue scale at the mealtimes, averaged over the study day, and categorized as no pain, slight, moderate or severe pain. The coverage of energy needs was expressed in percentage of predicted needs. RESULTS: Among the 755 included patients, 63% reported having pain. Severe pain was associated with a lower energy coverage than no pain (p = 0.001) or slight pain (p = 0.001). Insufficient energy coverage, defined as ≤70% of predicted needs, occurred in 13% of the patients. In univariate logistic regressions, predictors of insufficient energy coverage were severe pain as compared to no pain (OR 2.38; 95% CI 1.21, 4.64) and treatment with opioid drugs as compared to no pain killer (OR 1.73; 95% CI 1.07, 2.79). When including sex, age, body mass index, treatment with analgesics and severity of pain in a multivariate logistic regression, severe pain more than doubled the risk of insufficient energy coverage (OR 2.32; CI 1.15, 4.66). CONCLUSIONS: Patients experiencing severe pain have a high risk of insufficient energy coverage. Optimal pain control is probably critical to prevent underfeeding in the hospital. TRIAL REGISTRATION: Identifier no NCT02463565 on www.ClinicalTrials.gov.

Neurocognitive disorders: what are the prioritized caregiver needs? A consensus obtained by the Delphi method.

BACKGROUND: The symptoms related to neurocognitive disorders (NCD) may lead to caregiver burden increase. Involving caregivers in research may be an effective way of improving the practicalities and relevance of interventions. The aim of this study was to gather opinion and gain consensus on the caregivers 'priorities, using a Delphi method and including aspects of needs in pharmaceutical dimension. METHODS: Observational study using a modified Delphi method. This study was conducted in the Clinical and Research Memory Center of the University Hospital of Lyon (France), between September 2015 and January 2016. The expert panel was composed of 68 informal caregivers of people with subjective cognitive decline or NCD living at home. RESULTS: Caregivers assigned a very high importance to the dimension "information needs about their relative's disease", i.e. information on the disease, the treatment and the research; and to "coping skills", i.e. skills related to emotional support, communication, relationship evolution with the relative and skills to cope with behavioural crisis, behavioural and cognitive disorders. The aspect "coping with behavioural disorders" received a high selection rate (83%). CONCLUSIONS: The main needs selected can be used to design relevant interventions and give guidance to policy to support caregivers. To meet caregiver's needs, interventions should focus on information about disease and treatment and psychoeducational interventions.

Reliability of the revised Swiss Emergency Triage Scale: a computer simulation study.

BACKGROUND: The Swiss Emergency Triage Scale (SETS) is a four-level emergency scale that previously showed moderate reliability and high rates of undertriage due to a lack of standardization. It was revised to better standardize the measurement and interpretation of vital signs during the triage process. OBJECTIVE: The aim of this study was to explore the inter-rater and test-retest reliability, and the rate of correct triage of the revised SETS. PATIENTS AND METHODS: Thirty clinical scenarios were evaluated twice at a 3-month interval using an interactive computerized triage simulator by 58 triage nurses at an urban teaching emergency department admitting 60 000 patients a year. Inter-rater and test-retest reliabilities were determined using κ statistics. Triage decisions were compared with a gold standard attributed by an expert panel. Rates of correct triage, undertriage, and overtriage were computed. A logistic regression model was used to identify the predictors of correct triage. RESULTS: A total of 3387 triage situations were analyzed. Inter-rater reliability showed substantial agreement [mean κ: 0.68; 95% confidence interval (CI): 0.60-0.78] and test-retest almost perfect agreement (mean κ: 0.86; 95% CI: 0.84-0.88). The rate of correct triage was 84.1%, and rates of undertriage and overtriage were 7.2 and 8.7%, respectively. Vital sign measurement was an independent predictor of correct triage (odds ratios for correct triage: 1.29 for each additional vital sign measured, 95% CI: 1.20-1.39). CONCLUSION: The revised SETS incorporating standardized vital sign measurement and interpretation during the triage process resulted in high reliability and low rates of mistriage.

Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial.

BACKGROUND: Care of frail and dependent older adults with multiple chronic conditions is a major challenge for health care systems. The study objective was to test the efficacy of providing integrated care at home to reduce unnecessary hospitalizations, emergency room visits, institutionalization, and mortality in community dwelling frail and dependent older adults. METHODS: A prospective controlled trial was conducted, in real-life clinical practice settings, in a suburban region in Geneva, Switzerland, served by two home visiting nursing service centers. Three hundred and one community-dwelling frail and dependent people over 60 years old were allocated to previously randomized nursing teams into Control (N = 179) and Intervention (N = 122) groups: Controls received usual care by their primary care physician and home visiting nursing services, the Intervention group received an additional home evaluation by a community geriatrics unit with access to a call service and coordinated follow-up. Recruitment began in July 2009, goals were obtained in July 2012, and outcomes assessed until December 2012. Length of follow-up ranged from 5 to 41 months (mean 16.3). Primary outcome measure was the number of hospitalizations. Secondary outcomes were reasons for hospitalizations, the number and reason of emergency room visits, institutionalization, death, and place of death. RESULTS: The number of hospitalizations did not differ between groups however, the intervention led to lower cumulative incidence for the first hospitalization after the first year of follow-up (69.8%, CI 59.9 to 79.6 versus 87 · 6%, CI 78 · 2 to 97 · 0; p = .01). Secondary outcomes showed that the intervention compared to the control group had less frequent unnecessary hospitalizations (4.1% versus 11.7%, p = .03), lower cumulative incidence for the first emergency room visit, 8.3%, CI 2.6 to 13.9 versus 23.2%, CI 13.1 to 33.3; p = .01), and death occurred more frequently at home (44.4 versus 14.7%; p = .04). No significant differences were found for institutionalization and mortality. CONCLUSIONS: Integrated care that included a home visiting multidisciplinary geriatric team significantly reduced unnecessary hospitalizations, emergency room visits and allowed more patients to die at home. It is an effective tool to improve coordination and access to care for frail and dependent older adults. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT02084108 . Retrospectively registered on March 10th 2014.

Identification and comparison of the predictors of maximal inspiratory force and handgrip in a healthy elderly population. The proof study.

BACKGROUND: A severe weakness of peripheral muscles occurs in half of the persons aged 80 years or older. The common factors between muscle depletion and reduced respiratory strength have not yet been established. OBJECTIVE: In the subjects of the Proof cohort, we aimed to identify, among body composition, pulmonary function and energy expenditure parameters, the predictors of maximal inspiratory pressure (MIP) as an index of respiratory muscle strength and handgrip (HG) as an index of peripheral muscle strength. SUBJECTS AND METHODS: In 375 healthy elderly subjects aged 72 ± 1 years, fat mass (FM) and fat free mass (FFM) were assessed by DEXA, the last being also indexed to height (FFMI). Spirometry was performed and daily energy expenditure (DEE) was estimated by a questionnaire. After three years, MIP and HG of the dominant arm were determined and the predicting value of pulmonary function tests, body composition and DEE on these parameters was tested. RESULTS: Mean MIP and HG were 77 ± 26% and 106 ± 19% of the predicted value (%pred) with 90 (24%) and 30 (8%) subjects below standards, respectively. There was a significant but weak correlation between MIP%pred and HG%pred (r = 0.175, p < 0.001). Logistic regression showed that low MIP was predicted by trunk FFM and FFMI in women, and DEE in men. Low HG was predicted by trunk FM in men only. CONCLUSIONS: The predictors of a reduction of MIP in the elderly differ from those of HG, suggesting a differential regulation of respiratory muscle and arm strength.

Healthcare-associated infections are associated with insufficient dietary intake: an observational cross-sectional study.

BACKGROUND: Indicators to predict healthcare-associated infections (HCAI) are scarce. Malnutrition is known to be associated with adverse outcomes in healthcare but its identification is time-consuming and rarely done in daily practice. This cross-sectional study assessed the association between dietary intake, nutritional risk, and the prevalence of HCAI, in a general hospital population. METHODS AND FINDINGS: Dietary intake was assessed by dedicated dieticians on one day for all hospitalized patients receiving three meals per day. Nutritional risk was assessed using Nutritional Risk Screening (NRS)-2002, and defined as a NRS score ≥ 3. Energy needs were calculated using 110% of Harris-Benedict formula. HCAIs were diagnosed based on the Center for Disease Control criteria and their association with nutritional risk and measured energy intake was done using a multivariate logistic regression analysis. From 1689 hospitalised patients, 1024 and 1091 were eligible for the measurement of energy intake and nutritional risk, respectively. The prevalence of HCAI was 6.8%, and 30.1% of patients were at nutritional risk. Patients with HCAI were more likely identified with decreased energy intake (i.e. ≤ 70% of predicted energy needs) (30.3% vs. 14.5%, P = 0.002). The proportion of patients at nutritional risk was not significantly different between patients with and without HCAI (35.6% vs.29.7%, P = 0.28), respectively. Measured energy intake ≤ 70% of predicted energy needs (odds ratio: 2.26; 95% CI: 1.24 to 4.11, P = 0.008) and moderate severity of the disease (odds ratio: 3.38; 95% CI: 1.49 to 7.68, P = 0.004) were associated with HCAI in the multivariate analysis. CONCLUSION: Measured energy intake ≤ 70% of predicted energy needs is associated with HCAI in hospitalised patients. This suggests that insufficient dietary intake could be a risk factor of HCAI, without excluding reverse causality. Randomized trials are needed to assess whether improving energy intake in patients identified with decreased dietary intake could be a novel strategy for HCAI prevention.

Impaired baroreflex sensitivity and the risks of new-onset ambulatory hypertension, in an elderly population-based study.

BACKGROUND: Impairment of the autonomic nervous system activity may be involved in the development of hypertension. Yet the prognostic values of heart rate variability and baroreflex sensitivity in the risk of new-onset ambulatory hypertension have not been investigated. We sought to assess the relationship between heart rate variability and baroreflex sensitivity parameters and ambulatory hypertension in a community-dwelling elderly cohort. METHODS: Normotensive subjects were selected from the PROOF study cohort, including 1011 subjects aged 65 years at baseline. The autonomic nervous system activity was assessed through 24-hour heart rate variability and 15-minute spontaneous baroreflex sensitivity at baseline. Incident hypertension was defined with the 24-hour, day-time and night-time ambulatory blood pressure measurements and antihypertensive treatment use, at two-years of follow-up. RESULTS: At baseline, 13.7% of subjects developed day-time hypertension, 18.2% developed night-time hypertension and 13.6% developed 24-hour hypertension. Reduced baroreflex sensitivity at baseline was associated with onset of hypertension after adjustment for blood pressure level, C-reactive protein levels and depression score (OR = 0.45 [0.23-0.86]). Indices of heart rate variability were not associated with hypertension onset. CONCLUSION: Baroreflex sensitivity may represent an intermediate goal for prevention of ambulatory hypertension at early stage.

Primary attributions in women suffering fibromyalgia emphasize the perception of a disruptive onset for a long-lasting pain problem.

OBJECTIVE: Fibromyalgia (FM) is a chronic musculoskeletal pain disorder characterized by widespread pain. This study focuses on patients' attributions of illness and of symptom onset. METHODS: Semi-structured interviews were conducted with 56 women to elicit patients' views on what triggered their FM. The transcripts of the interviews were analyzed using a classical indexing technique to identify key themes. Content analysis was performed by two independent coders. RESULTS: Primary causal attributions fell into five categories: psychological problems (28 respondents); somatic concerns (N=12); violence/abuse during childhood (N=7), gynaecological/obstetrical problems (N=6), and fatigue (N=3). Patients' attributions were internal and external in the same proportions, more frequently unstable than stable, and more often described uncontrollable than controllable. Participants expressed decrements in self-esteem and feelings such as self-blame or despair; global perceptions of persistent pain and long-lasting problems, evoking chronicity and hopelessness; and low perceived control over their lives as well as beliefs that nothing can be done, thus increasing a feeling of guilt and vulnerability. Patients' narratives emphasized disruptive circumstances surrounding symptom onset. CONCLUSION: Attributions often referred to the psychological dimension of the events surrounding FM onset, even though some of them also had a clear somatic dimension. Many narratives mentioned successive disruptive events and suggested an increasing loss of control. Addressing these illness representations may contribute to tailor the treatment and to help patients gain self-coherency by providing means to understand pain onset but also to guide future behaviours, particularly in terms of adjustment and help-seeking.

Depressive symptoms and autonomic nervous system dysfunction in an elderly population-based study: the PROOF study.

BACKGROUND: To assess the relationship between depressive symptoms, evaluated through self-reported history as well as current depressive symptoms, and impaired autonomic nervous system activity, evaluated by long-term heart rate variability and baroreflex sensitivity among elderly community residents, aged 65 years. METHODS: Subjects from the Proof cohort Study were evaluated for depressive symptoms and self-reported history of depression at inclusion. Autonomic nervous system activity was assessed through 24-h heart rate variability and baroreflex sensitivity. Cross-sectional analyses were performed to study the relationship between the different status of depression and autonomic nervous system activity. RESULTS: Among the 1011 Proof study participants, 823 subjects were included in the analyses. Current depressive symptoms were present among 67 subjects; history of depression was reported by 228 subjects. Psychoactive drugs were used by 59 subjects. Low frequency (p=0.02), very low frequency (p<0.01) and Low/High frequency ratio (p<0.001) were lower among subjects with depressive symptoms and history of depression, independently of antidepressant treatment. The association remained significant for Low/High frequency ratio after adjustment for gender and physical activity (p=0.004). CONCLUSION: Current depressive symptoms may be linked to autonomic nervous system lower performances. A possible long-term effect of depressive symptoms at middle-age may influence later-life autonomic nervous system activity. Our results highlight the importance of taking into account the depressive symptoms in the cardiovascular risk, even in the elderly.

Fondaparinux versus enoxaprin in the management of acute coronary syndromes in Switzerland: A cost comparison analysis.

QUESTION UNDER STUDY: Anticoagulation therapy is routinely used in cases of non ST-segment elevation acute coronary syndromes (NSTE-ACS). The most commonly used drug in such events is enoxaparin, a low molecular weight heparin. Fondaparinux, a synthetic pentasaccharide, is as effective as enoxaparin in terms of survival or residual angina pectoris and significantly reduces bleeding complications. The purpose of this study was to assess the magnitude of cost reductions if enoxaparin were replaced by fondaparinux in Switzerland. METHODS: Costs of hospital stay for NSTE-ACS with or without bleeding complications at the Geneva University Hospitals were determined for patients admitted between July 1st, 2007 and June 30th, 2008. These costs were applied to subjects recruited in the AMIS Plus registry, which gathers information on ACS in Swiss hospitals, using three scenarios. Firstly, using the baseline incidence of bleeding episodes observed in the AMIS plus registry. Secondly, using the baseline incidence of haemorrhagic episodes observed in the Geneva University Hospitals sample and thirdly, using the incidence of haemorrhagic episodes observed in the OASIS-5 study. These results and costs were then extrapolated to the national level. RESULTS: At the Swiss national level, replacement of enoxaparin by fondaparinux would generate annual savings ranging from 854,000 Swiss Francs (scenario 1) to 3,400,000 Swiss Francs (scenario 2) and 2,845,000 Swiss Francs (scenario 3). Estimated savings accounted for 55 to 63% of total hospital costs. CONCLUSIONS: Use of fondaparinux instead of enoxaparin in patients with NSTE-ACS could yield substantial savings at the local as well as the national level in Switzerland.

Obstructive sleep apnea and the metabolic syndrome in an elderly healthy population: the SYNAPSE cohort.

BACKGROUND: Obstructive sleep apnea syndrome (OSA) has been recently considered as a cause and a component of the metabolic syndrome (MetS), previous studies showing the presence of OSA in about half of middle-aged patients having MetS. To date, no study has considered the association of OSA and MetS in the elderly. In this study we examine the prevalence of MetS and its strength association among healthy elderly OSA subjects. METHODS: A cohort of 806 subjects aged 68.5 years, participants of a 7-year follow-up study, was examined. All subjects underwent clinical evaluation, blood sample measurements, and an at-home polygraphy. OSA was assessed as an apnea/hypopnea index (AHI) >15, and MetS was diagnosed according to the Adult Treatment Panel III. RESULTS: In the total group, 9.8% of cases met criteria for MetS with a prevalence similar in men and women. Of the entire group with Mets, 51.3% were women and 48.7% men. OSA was diagnosed in 55.9% of the sample, and among the OSA group, 12.5% had MetS. Oxyhemoglobin desaturation index (ODI, p < 0.0001) and AHI (p = 0.003) were found significantly higher in subjects with MetS than in those without it. Most of MetS components were significantly associated with AHI and ODI, the relationship stronger with ODI. After adjustment for covariables such as obesity, gender, and presence of diabetes, ODI was independently associated with three MetS components, glycemia (p < 0.0001), hypertension (p = 0.002), and triglyceride levels (p = 0.02). Sleepiness, autonomic arousal index, and sleep duration had no effect on the metabolic parameters. CONCLUSIONS: In elderly subjects, the association between OSA and MetS was stronger for hyperglycemia and hypertension. Among factors explaining this association, hypoxemia appears to be the most important factor without any effect of indices of sleep fragmentation, sleep duration, and sleepiness.

Improvement of measles immunity among migrant populations: lessons learned from a prevalence study in a Swiss prison.

BACKGROUND: Measles persists worldwide despite the implementation of general vaccination campaigns. The environmental and demographic characteristics in many prisons increase the risk of measles epidemics. A large proportion of inmates come from countries where immunisation coverage is low. We aimed to estimate the susceptibility to measles among prisoners in order to implement preventative measures. METHODS: Serology screening for measles was carried out among 116 inmates in Switzerland's largest pre-trial prison. Socio-demographic characteristics were collected through a structured questionnaire. Risk factors for lack of measles immunity were examined. RESULTS: A total of 7 out of 116 (6%) inmates were not immune to measles. All 37 inmates from sub-Saharan Africa were immune. Considering only people native from regions other than sub-Saharan Africa, 7 of 40 inmates born after 1981 were susceptible (18.5%), whereas none of the 39 inmates born in 1981 or before were susceptible (p = 0.006). CONCLUSION: Susceptibility to measles was fairly low in this prison population composed mainly of migrants. Living in sub-Saharan Africa during childhood, and birth before 1982 were protective factors associated with the presence of immunity against measles. The heterogeneity of vaccination campaigns in the various regions of the world, particularly in terms of the timing of their introduction and scale of diffusion, explains epidemiological variability. Targeted vaccination in accordance to origin and age would offer excellent herd immunity and would substantially reduce risks of outbreaks as well as costs.

Increased waist circumference is the component of metabolic syndrome the most strongly associated with elevated C-reactive protein in elderly.

BACKGROUND: Metabolic syndrome is associated with higher C-reactive protein (CRP) serum levels, a common biological marker of inflammation. However, the respective contribution of each component of metabolic syndrome to the inflammation has not been established. The aim of the present study was to assess the strength of the association between metabolic syndrome components and CRP in elderly subjects. METHODS: This was an observational, cross-sectional study on 921 volunteers (65.6 ± 0.8 years old) from the PROOF (PROgnostic indicator OF cardiovascular and cerebrovascular events) Study. Anthropometric, biological, and clinical parameters were evaluated. Subjects with a CRP value less than 10 mg/L were considered. The relationships between the metabolic syndrome components and CRP tertiles were evaluated using logistic regression analysis. RESULTS: After adjustment for gender and for body mass index, metabolic syndrome and high-CRP tertile were significantly associated [odds ratio (OR)=2.37, 95% confidence interval (CI) 1.46-3.87, P<0.001]. Waist circumference demonstrated the strongest association with the high-CRP tertile (OR=1.75, 95% CI 1.05-2.91, P<0.05). In addition, CRP levels significantly increased with the number of metabolic syndrome components. CONCLUSIONS: Among metabolic syndrome components, waist circumference showed the strongest association with the high-CRP tertile in elderly subjects. These findings help to explain the strong association between waist circumference and cardiovascular morbidity.

The quality of primary care in a country with universal health care coverage.

BACKGROUND: Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage. OBJECTIVE: To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage. DESIGN AND PARTICIPANTS: Retrospective cohort of a random sample of 1,002 patients aged 50-80 years followed for 2 years from all Swiss university primary care settings. MAIN MEASURES: We used indicators derived from RAND's Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator. KEY RESULTS: Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including >75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients <65 years (70.1% vs 68.0% in those ≥ 65 years, p = 0.047). CONCLUSIONS: Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.

Body composition changes over 9 years in healthy elderly subjects and impact of physical activity.

BACKGROUND & AIMS: Age-related changes of body composition affect health status. This study aims at clarifying body composition changes in healthy elderly subjects, and evaluating the impact of physical activity on these changes. METHODS: In 1999, 213 subjects ≥ 65 years recruited through advertisements underwent assessment of health state, energy expenditure by physical activity, body composition by bioimpedance analysis and body cell mass by total body potassium. In 2008, 112 of them repeated these assessments with additional determination of Barthel index, Mini Mental State Examination and Geriatric Depression Score. RESULTS: Lean tissues decreased in both genders (p < 0.05). Compared to subjects aged 65-74 years at baseline, those aged ≥75 years lost more body weight (men: -3.7 ± 5.4 vs. 0.4 ± 5.4 kg, women: -3.6 ± 5.5 vs. 0.3 ± 5.2 kg, both p < 0.05), and fat-free mass (men: -3.6 ± 3.3 vs. -0.4 ± 2.7 kg, women: -1.8 ± 2.3 vs. -0.1 ± 2.5 kg, both p < 0.05). Plotting of fat-free mass evolution against age at baseline showed an exponential loss of fat-free mass. Increased physical activity limited lean tissue loss in men but not in women. CONCLUSION: Loss of lean tissues occurs exponentially with aging. Further research should confirm these changes in subjects over 80 years. Increasing physical activity limits fat-free mass loss in men but not women.

[Integration of nutritional care into cancer treatment: need for improvement]. / Soin nutritionnel intégré au soin oncologique: un besoin d'optimisation.

Progresses in cancer treatment transformed cancer into a chronic disease associated with growing nutritional problems. Poor nutritional status of cancer patients worsens morbidity, mortality, overall cost of care and decreases patients' quality of life, oncologic treatments tolerance and efficacy. These adverse effects lead to treatment modifications or interruptions, reducing the chances to control or cure cancer. Implementation of an interdisciplinary and longitudinal integration of nutritional care and nutritional information into cancer treatment (The OncoNut Program) could prevent or treat poor nutritional status and its adversely side effects.

Assessment of food intake in hospitalised patients: a 10-year comparative study of a prospective hospital survey.

BACKGROUND & AIMS: A food quality control and improvement permanent process was initiated in 1999. To evaluate the food service evolution, protein-energy needs coverage were compared in 1999 and 2008 with the same structure survey in all hospitalized patients receiving 3 meals/day. METHODS: Nutritional values of food provided, consumed and wasted over 24h including non-exclusive nutritional support were calculated individually. Nutritional needs were estimated as 110% of Harris-Benedict formula for energy and 1.2 or 1.0 g protein/kg/day for patients <65 or ≥65 years old, respectively. Multivariate analysis identified factors associated with low nutritional intake in both populations standardized to body mass index (BMI) of 1999's patients. RESULTS: Out of 1677 patients, 1291 were included. Mean BMI was higher in 2008 than 1999 (P<0.001). The proportion of underfed patients was unchanged (69 vs. 70%, NS). The consumption of ≥1 oral nutritional supplements (ONS) daily increased the protein needs coverage from 80% to 115% (P<0.001). The year 1999, high BMI, 1st week of hospital stay, specific diet, ONS absence and low meal quality were associated with low nutritional intakes. CONCLUSION: The nutritional needs coverage could have improved in 2008 if BMI was similar to 1999's. ONS consumption is associated with a lower risk of underfeeding in hospitalized patients.

Reduction of missed appointments at an urban primary care clinic: a randomised controlled study.

BACKGROUND: Missed appointments are known to interfere with appropriate care and to misspend medical and administrative resources. The aim of this study was to test the effectiveness of a sequential intervention reminding patients of their upcoming appointment and to identify the profile of patients missing their appointments. METHODS: We conducted a randomised controlled study in an urban primary care clinic at the Geneva University Hospitals serving a majority of vulnerable patients. All patients booked in a primary care or HIV clinic at the Geneva University Hospitals were sent a reminder 48 hrs prior to their appointment according to the following sequential intervention: 1. Phone call (fixed or mobile) reminder; 2. If no phone response: a Short Message Service (SMS) reminder; 3. If no available mobile phone number: a postal reminder. The rate of missed appointment, the cost of the intervention, and the profile of patients missing their appointment were recorded. RESULTS: 2123 patients were included: 1052 in the intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded at the clinic. The sequential intervention significantly reduced the rate of missed appointments: 11.4% (n = 122) in the control group and 7.8% (n = 82) in the intervention group (p < 0.005), and allowed to reallocate 28% of cancelled appointments. It also proved to be cost effective in providing a total net benefit of 1846. - EUR/3 months. A satisfaction survey conducted with 241 patients showed that 93% of them were not bothered by the reminders and 78% considered them to be useful. By multivariate analysis, the following characteristics were significant predictors of missed appointments: younger age (OR per additional decade 0.82; CI 0.71-0.94), male gender (OR 1.72; CI 1.18-2.50), follow-up appointment >1 year (OR 2.2; CI: 1.15-4.2), substance abuse (2.09, CI 1.21-3.61), and being an asylum seeker (OR 2.73: CI 1.22-6.09). CONCLUSION: A practical reminder system can significantly increase patient attendance at medical outpatient clinics. An intervention focused on specific patient characteristics could further increase the effectiveness of appointment reminders.

Autonomic nervous system activity is independently associated with the risk of shift in the non-dipper blood pressure pattern.

An insufficient decrease in nocturnal blood pressure (BP) is a known factor in cardiovascular mortality. We aimed to determine whether autonomic nervous system (ANS) activity and its change over 2 years were associated with a shift to non-dipper status, independently of initial BP, in a general elderly population. From participants in the PROOF study, 600 subjects untreated for hypertension were selected (age at baseline: 65 years, men: 41.5%). Dipper/non-dipper status was defined using repeated measures of 24-h ambulatory BP at baseline and 2 years later. ANS activity was evaluated on the basis of 24-h heart rate variability at both examinations. Among the 454 dipper subjects at baseline, 26.2% became non-dippers. Multivariate analysis showed that a +1 between-subject s.d. increase in the very low frequency at baseline was associated with a decreased odds ratio for the shift to non-dipper status 2 years later (OR=0.61 [0.41-0.91], P=0.02). The within-subject change between the two measurements of day and night systolic BP and day diastolic BP also contributed significantly to the risk of shift to non-dipper status. Our results suggest that impaired ANS activity precedes an insufficient decrease in nocturnal BP independent of hypertension status.

Stairs instead of elevators at workplace: cardioprotective effects of a pragmatic intervention.

BACKGROUND: Population strategies to increase physical activity are an essential part of cardiovascular disease prevention. However, little data exist on lifestyle interventions that are easy to integrate into everyday life such as using stairs instead of elevators at the workplace. DESIGN: Pre and postintervention study. METHODS: A 12-week promotional campaign for stair use consisting in posters and floor stickers at the point of choice between stairs and elevators at each hospital floor was organized in a university hospital building. In 77 selected employees with an inactive lifestyle, physical activity, aerobic fitness, anthropometrics, blood pressure, lipids, insulin sensitivity, and C-reactive protein were assessed at baseline, 12 weeks, and 6 months. RESULTS: During the intervention median daily number of ascended and descended one-story staircase units was 20.6/day (14.2-28.1) compared with 4.5/day (1.8-7.2) at baseline (P<0.001). At 12 weeks, estimated maximal aerobic capacity had increased by 9.2±15.1% (P<0.001) corresponding with approximately 1 MET. There were significant declines in waist circumference (-1.7±2.9%), weight (-0.7±2.6%), fat mass (-1.5±8.4%), diastolic blood pressure (-1.8±8.9%), and low-density lipoprotein cholesterol (-3.0±13.5%). At 6 months, the median daily number of ascended and descended one-story staircase units had decreased to 7.2 (3.5-14.0). Benefits on estimated maximal aerobic capacity (+5.9±12.2%, P=0.001) and fat mass (-1.4±8.4%, P=0.038) persisted. CONCLUSION: Encouraging stair use at work is effective for improving fitness, body composition, blood pressure, and lipid profile in asymptomatic individuals with an inactive lifestyle and thus may be a simple way to significantly reduce cardiovascular disease risk at the population level.