NT-proBNP and Its Correlation with In-Hospital Mortality in the Very Elderly without an Admission Diagnosis of Heart Failure.

BACKGROUND: The diagnosis of heart failure (HF) is often difficult and underestimated in very elderly comorbid patients, especially when an echocardiographic evaluation is not available or feasible. AIM: to evaluate NT-proBNP values and their correlation with in-hospital mortality in a population of very elderly hospitalized for medical conditions other than HF. METHODS: We performed a prospective observational study on 403 very elderly admitted to an Internal Medicine and Geriatrics Department. Exclusion criterion was an admission diagnosis of HF. Patients with at least one symptom or sign compatible with HF were tested for NT-proBNP. NT-proBNP values < 300 pg/ml were considered as an age-independent exclusion criterion for HF (high negative predictive value), while NT-proBNP values ≥ 1800 pg/ml were considered as a diagnostic criterion. Main comorbidities and laboratory parameters were considered to adjust regression analyses between NT-proBNP and in-hospital mortality. RESULTS: NT-proBNP values ≥ 1800 pg/ml were present in 61.0% of patients and 32.8% of patients laid between 300 ≤ NT-proBNP < 1800 pg/ml values. NT-proBNP values were associated with the main indices of disease severity/organ failure considered such as reduced eGFR, reduced albumin and elevated CRP. NT-proBNP values ≥ 1800 pg/ml and ln(NT-proBNP) values were significantly associated with in-hospital mortality independently from the main comorbidities and lab parameters considered. The patients, who were already taking ACE inhibitors/Angiotensin Receptor Blockers before admission, showed lower in-hospital mortality. CONCLUSIONS: Testing for NT-proBNP should be strongly recommended in the hospitalized very elderly, because of the very high prevalence of underlying HF and its impact on in-hospital mortality, to identify an underlying cardiac involvement that requires appropriate treatment.

Efficacy of Non-Pharmacological Interventions to Prevent and Treat Delirium in Older Patients: A Systematic Overview. The SENATOR project ONTOP Series.

BACKGROUND: Non-pharmacological intervention (e.g. multidisciplinary interventions, music therapy, bright light therapy, educational interventions etc.) are alternative interventions that can be used in older subjects. There are plenty reviews of non-pharmacological interventions for the prevention and treatment of delirium in older patients and clinicians need a synthesized, methodologically sound document for their decision making. METHODS AND FINDINGS: We performed a systematic overview of systematic reviews (SRs) of comparative studies concerning non-pharmacological intervention to treat or prevent delirium in older patients. The PubMed, Cochrane Database of Systematic Reviews, EMBASE, CINHAL, and PsychINFO (April 28th, 2014) were searched for relevant articles. AMSTAR was used to assess the quality of the SRs. The GRADE approach was used to assess the quality of primary studies. The elements of the multicomponent interventions were identified and compared among different studies to explore the possibility of performing a meta-analysis. Risk ratios were estimated using a random-effects model. Twenty-four SRs with 31 primary studies satisfied the inclusion criteria. Based on the AMSTAR criteria twelve reviews resulted of moderate quality and three resulted of high quality. Overall, multicomponent non-pharmacological interventions significantly reduced the incidence of delirium in surgical wards [2 randomized trials (RCTs): relative risk (RR) 0.71, 95% Confidence Interval (CI) 0.59 to 0.86, I2=0%; (GRADE evidence: moderate)] and in medical wards [2 CCTs: RR 0.65, 95%CI 0.49 to 0.86, I2=0%; (GRADE evidence: moderate)]. There is no evidence supporting the efficacy of non-pharmacological interventions to prevent delirium in low risk populations (i.e. low rate of delirium in the control group)[1 RCT: RR 1.75, 95%CI 0.50 to 6.10 (GRADE evidence: very low)]. For patients who have developed delirium, the available evidence does not support the efficacy of multicomponent non-pharmacological interventions to treat delirium. Among single component interventions only staff education, reorientation protocol (GRADE evidence: very low)] and Geriatric Risk Assessment MedGuide software [hazard ratio 0.42, 95%CI 0.35 to 0.52, (GRADE evidence: moderate)] resulted effective in preventing delirium. CONCLUSIONS: In older patients multi-component non-pharmacological interventions as well as some single-components intervention were effective in preventing delirium but not to treat delirium.

Associations between body mass index, ambulatory blood pressure findings, and changes in cardiac structure: relevance of pulse and nighttime pressures.

Ambulatory blood pressure monitoring (ABPM) is central in the management of hypertension. Factors related to BP, such as body mass index (BMI), may differently affect particular aspects of 24-hour ABPM profiles. However, the relevance of BMI, the most used index of adiposity, has been underappreciated in the determination of specific aspects of 24-hour ABPM profiles in hypertension. The authors evaluated the association between BMI and aspects of ABPM together with their associations with cardiac remodeling in 1841 patients. A positive association of BMI with 24-hour, daytime, and nighttime pulse pressure in untreated normal weight and overweight/obese hypertensive patients and a positive association of BMI with nocturnal BP parameters in treated overweight/obese hypertensive patients was observed. The clinical relevance of these findings was supported by the positive significant correlations of BMI-related BPs with left ventricular mass and atrial diameter.

Circulating aldosterone and natriuretic peptides in the general community: relationship to cardiorenal and metabolic disease.

We sought to investigate the role of aldosterone as a mediator of disease and its relationship with the counter-regulatory natriuretic peptide (NP) system. We measured plasma aldosterone (n=1674; aged≥45 years old) in a random sample of the general population from Olmsted County, MN. In a multivariate logistic regression model, aldosterone analyzed as a continuous variable was associated with hypertension (odds ratio [OR]=1.75; 95% confidence interval [CI]=1.57-1.96; P<0.0001), obesity (OR=1.34; 95% CI=1.21-1.48; P<0.0001), chronic kidney disease (OR=1.39; 95% CI=1.22-1.60; P<0.0001), central obesity (OR=1.47; 95% CI=1.32-1.63; P<0.0001), metabolic syndrome (OR=1.41; 95% CI=1.26-1.58; P<0.0001), high triglycerides (OR=1.23; 95% CI=1.11-1.36; P<0.0001), concentric left ventricular hypertrophy (OR=1.22; 95% CI=1.09-1.38; P=0.0007), and atrial fibrillation (OR=1.24; 95% CI=1.01-1.53; P=0.04), after adjusting for age and sex. The associations with hypertension, central obesity, metabolic syndrome, triglycerides, and concentric left ventricular hypertrophy remained significant after further adjustment for body mass index, NPs, and renal function. Furthermore, aldosterone in the highest tertile correlated with lower NP levels and increased mortality. Importantly, most of these associations remained significant even after excluding subjects with aldosterone levels above the normal range. In conclusion, we report that aldosterone is associated with hypertension, chronic kidney disease, obesity, metabolic syndrome, concentric left ventricular hypertrophy, and lower NPs in the general community. Our data suggest that aldosterone, even within the normal range, may be a biomarker of cardiorenal and metabolic disease. Further studies are warranted to evaluate a therapeutic and preventive strategy to delay the onset and progression of disease, using mineralocorticoid antagonists or chronic NP administration in high-risk subjects identified by plasma aldosterone.

Hypertensive heart disease and obesity: a complex interaction between hemodynamic and not hemodynamic factors.

The worldwide prevalence of obesity has nearly doubled, with an increase in obesity-related cardiovascular disease and mortality. Several factors are involved in the genesis of hypertension and hypertensive heart disease (HHD) in overweight/obesity. This review is focused on bridging factors between excessive adiposity and HHD, presenting a unifying hypothesis of vascular-metabolic syndrome, where an "handicap" of the natriuretic peptide system has a central role both in adipocyte dysmetabolism as well as in increased blood pressure and HHD.

Chronic kidney disease is characterized by "double trouble" higher pulse pressure plus night-time systolic blood pressure and more severe cardiac damage.

BACKGROUND: Hypertension plays a key role in chronic kidney disease (CKD), but CKD itself affects the blood pressure (BP) profile. The aim of this study was to assess the association of BP profile with CKD and the presence of cardiac organ damage. METHODS: We studied 1805 patients, referred to our Hypertension Centre, in whom ABPM, blood tests, and echocardiography were clinically indicated. The glomerular filtration rate was estimated (eGFR) using the MDRD equation and CKD was defined as eGFR<60 mL/min/1.73 m(2). Cardiac organ damage was evaluated by echocardiography. RESULTS: Among patients with CKD there were higher systolic blood pressure (SBP) during the night-time, greater prevalence of non-dippers (OR: 1.8) and increased pulse pressure (PP) during 24-hour period, daytime and night-time (all p<0.001). Patients with CKD had a greater LVM/h(2.7) index, and a higher prevalence of left ventricular hypertrophy and diastolic dysfunction (all p<0.001). Nocturnal SBP and PP correlated more strongly with cardiac organ damage (p<0.001). Patients with CKD had a greater Treatment Intensity Score (p<0.001) in the absence of a significantly greater BP control. CONCLUSIONS: CKD patients have an altered night-time pressure profile and higher PP that translate into a more severe cardiac organ damage. In spite of a greater intensity of treatment in most patients with CKD, BP control was similar to patients without CKD. Our findings indicate the need of a better antihypertensive therapy in CKD, better selected drugs, dosages and posology to provide optimal coverage of 24 hours and night-time BP.

Nebivolol induces, via ß3 adrenergic receptor, lipolysis, uncoupling protein 1, and reduction of lipid droplet size in human adipocytes.

OBJECTIVES: Most ß-blockers may induce weight gain, dysglycemia, and dyslipidemia. Nebivolol is a third-generation ß1-blocker with vasodilating properties mediated by ß3 adrenergic receptors (ß3AR). We investigated whether nebivolol is able to induce ß3AR-mediated lipolysis, uncoupling protein 1 (UCP1), and size-reduction in human adipocytes. METHODS: Human visceral (n = 28) and subcutaneous adipose tissue (n = 26) samples were used to obtain differentiated subcutaneous and visceral preadipocytes. Adipocytes were used to verify the effects of nebivolol onlipolysis, uncoupling protein 1 (UCP1) and other genes of the thermogenic program. RESULTS: Lipolysis was induced by isoproterenol and specific ß3AR agonist, as expected,and also by nebivolol at 100 nmol/l and by its L-enantiomer at 10 nmol/l (P < 0.01). Nebivolol-mediated lipolysis was blocked by SR59230A, a specific ß3AR antagonist, suggesting that nebivolol acts through ß3AR in human adipocytes. Interestingly, in human adipocytes, nebivolol activated UCP1, PPARγ coactivator-1α (PGC-1α) and cytochrome c (CYCS) gene expression in a p38 MAPK-dependent manner. Using propranolol (ß1 and ß2 antagonist) together with nebivolol we showed that the induction of these genes was still present suggesting again ß3AR activation. Moreover, nebivolol significantly reduced the diameter of lipid droplets in cultured adipocytes. CONCLUSION: In summary, nebivolol, through ß3AR, is able to induce lipolysis and promote thermogenic and mitochondrial genes. The induction of lipolysis and the thermogenic program could explain the reduction of lipid droplets size. In conclusion, the lower dysmetabolic effects of nebivolol in humans may depend on its ß3 agonist activity and the consequent induction of thermogenic program in human adipocytes.

Pattern of use and presenting complaints of older patients visiting an Emergency Department in Italy.

BACKGROUND AND AIMS: The number of older persons admitted to the Emergency Department (ED) is dramatically increasing due to their complex medical and social problems, which in turn lead to longer clinical evaluation times and increased use of resources compared to younger adults. However, scant data are available for Italian EDs. Similarly, no data are available about the reasons to ED visit and its role in determining the ED utilization pattern. The study aimed at describing the pattern of ED use by older patients and main presenting complaints. METHODS: Cross-sectional descriptive study of 5,826 ED patients in the city of Fano (Italy). Identifiers and triage, clinical and social data were collected. Presenting complaints as recorded by triage nurses have been recoded according to the Canadian Emergency Department Information System list version 1.1. Data were analyzed comparing older patients (more than 65 years-old) with younger adults (less than 65 years-old). RESULTS: The prevalence of ED visits by older adults was 23.9 %. Their visits were characterized by higher emergency levels, admission rate and length of ED stay. Trauma was the main reason for ED presentation, especially among young adults, but elderly trauma patients were more frequently admitted because of hip fracture. Dyspnea and abdominal pain were the most frequent non-trauma presenting complaints among geriatric patients and represented the main causes for admission. CONCLUSIONS: Older adults use the ED appropriately also in Italy. Trauma with complications (fracture) and various presenting complaints underlying medical problems accounted for more than 50 % of ED visits and hospital admissions.

Summer does not always mean lower: seasonality of 24 h, daytime, and night-time blood pressure.

OBJECTIVE: Evaluation of seasonal influences on ambulatory blood pressure monitoring (ABPM) values in a very large population living in a mild-climate geographic area. METHODS: Among patients referred to our Hypertension Center between September 2002 and January 2011 with a reliable ABPM, we considered those in the two hottest (July and August) vs. those in the two coldest (January and February) months. RESULTS: Seven hundred and forty-two men (53.2%) and 653 women (46.8%) were studied; 1245 (89.3%) were hypertensive patients of which 795 (63.9%) were drug-treated. In winter, mean daytime SBP and DBP were higher (P = 0.001 and P < 0.001, respectively), but only 24-h DBP was significantly higher (P = 0.012). On the contrary, higher night-time SBP and pulse pressure were recorded in summer (P = 0.005 and P = 0.023, respectively). Uncontrolled hypertensive patients had the highest mean difference between winter and summer night-time SBP (127.1 ± 13.4 vs. 131.0 ± 12.6 mmHg; P = 0.001). In winter a dipping pattern was prevalent (58.2%), whereas in summer a nondipping pattern prevailed (61.9%; P < 0.001). Isolated nocturnal hypertension (INH) was present in 9.8% in winter vs. 15.2% in summer (P = 0.003). CONCLUSION: Our data on a very large ABPM sample confirmed that hottest summer months are associated with lower daytime BP and also lower 24-h DBP. However, we found an inverse relationship regarding night-time BP, dipping pattern, and INH that were higher or more common in summer. These findings were even more evident in treated patients, especially when not at target. Different sleeping behaviors or improper dose reduction of drug therapy in summer may explain the findings.

Plasma aldosterone is increased in class 2 and 3 obese essential hypertensive patients despite drug treatment.

BACKGROUND: The aim of this study was to evaluate whether body mass index (BMI) is independently correlated with plasma aldosterone concentration (PAC) in treated essential hypertensive patients, and whether the relationship between BMI and high blood pressure (BP) can be partially mediated by PAC despite renin-angiotensin-aldosterone system blockade. METHODS: This study used a cross-sectional design and included 295 consecutive essential hypertensive patients referred to our centre for uncontrolled BP despite stable antihypertensive treatment for at least 6 months. The main exclusion criteria were age >65 years; glomerular filtration rate <30 ml/min; and therapy with mineralocorticoid receptor antagonists, direct renin inhibitors, amiloride or oral contraceptives. RESULTS: Higher levels of obesity showed a significantly higher mean PAC with a steep nonlinear increase in patients with BMI ≥ 35 kg/m(2). Class 2 and 3 obese patients had a higher mean PAC than nonobese and class 1 obese patients, even in patients under stable treatment with either angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). In a stepwise multiple linear regression model, only log of plasma renin activity (PRA), mean blood pressure (MBP), and class 2 and 3 obesity showed an independent correlation with PAC. In the same model applied to patients treated with ACEIs or ARBs, only logPRA and class 2 and 3 obesity showed a direct correlation with PAC. CONCLUSIONS: In treated essential hypertensive patients, a BMI ≥ 35 kg/m(2) is independently, albeit modestly, correlated with PAC. The correlation between BMI ≥ 35 kg/m(2) and PAC holds true even in ACEI/ARB-treated patients. Further study is required to determine whether the association of obesity with BP is mediated by PAC in hypertensive patients on stable therapy with ACEIs or ARBs.

Cardiac natriuretic peptides act via p38 MAPK to induce the brown fat thermogenic program in mouse and human adipocytes.

The ability of mammals to resist body fat accumulation is linked to their ability to expand the number and activity of "brown adipocytes" within white fat depots. Activation of ß-adrenergic receptors (ß-ARs) can induce a functional "brown-like" adipocyte phenotype. As cardiac natriuretic peptides (NPs) and ß-AR agonists are similarly potent at stimulating lipolysis in human adipocytes, we investigated whether NPs could induce human and mouse adipocytes to acquire brown adipocyte features, including a capacity for thermogenic energy expenditure mediated by uncoupling protein 1 (UCP1). In human adipocytes, atrial NP (ANP) and ventricular NP (BNP) activated PPARγ coactivator-1α (PGC-1α) and UCP1 expression, induced mitochondriogenesis, and increased uncoupled and total respiration. At low concentrations, ANP and ß-AR agonists additively enhanced expression of brown fat and mitochondrial markers in a p38 MAPK-dependent manner. Mice exposed to cold temperatures had increased levels of circulating NPs as well as higher expression of NP signaling receptor and lower expression of the NP clearance receptor (Nprc) in brown adipose tissue (BAT) and white adipose tissue (WAT). NPR-C(-/-) mice had markedly smaller WAT and BAT depots but higher expression of thermogenic genes such as Ucp1. Infusion of BNP into mice robustly increased Ucp1 and Pgc-1α expression in WAT and BAT, with corresponding elevation of respiration and energy expenditure. These results suggest that NPs promote "browning" of white adipocytes to increase energy expenditure, defining the heart as a central regulator of adipose tissue biology.

The association of left ventricular hypertrophy with metabolic syndrome is dependent on body mass index in hypertensive overweight or obese patients.

BACKGROUND: Overweight (Ow) and obesity (Ob) influence blood pressure (BP) and left ventricular hypertrophy (LVH). It is unclear whether the presence of metabolic syndrome (MetS) independently affects echocardiographic parameters in hypertension. METHODS: 380 Ow/Ob essential hypertensive patients (age ≤ 65 years) presenting for referred BP control-related problems. MetS was defined according to NCEP III/ATP with AHA modifications and LVH as LVM/h(2.7) ≥ 49.2 g/m(2.7) in males and ≥ 46.7 g/m(2.7) in females. Treatment intensity score (TIS) was used to control for BP treatment as previously reported. RESULTS: Hypertensive patients with MetS had significantly higher BMI, systolic and mean BP, interventricular septum and relative wall thickness and lower ejection fraction than those without MetS. LVM/h(2.7) was significantly higher in MetS patients (59.14 ± 14.97 vs. 55.33 ± 14.69 g/m(2.7); p = 0.022). Hypertensive patients with MetS had a 2.3-fold higher risk to have LVH/h(2.7) after adjustment for age, SBP and TIS (OR 2.34; 95%CI 1.40-3.92; p = 0.001), but MetS lost its independent relationship with LVH when BMI was included in the model. CONCLUSIONS: In Ow/Ob hypertensive patients MetS maintains its role of risk factor for LVH independently of age, SBP, and TIS, resulting in a useful predictor of target organ damage in clinical practice. However, MetS loses its independent relationship when BMI is taken into account, suggesting that the effects on MetS on LV parameters are mainly driven by the degree of adiposity.

Microalbuminuria and left ventricular mass in overweight and obese hypertensive patients: role of the metabolic syndrome.

BACKGROUND: Left ventricular hypertrophy (LVH) and microalbuminuria are common in hypertensive patients and are often associated with metabolic syndrome (MetS). However, it is not clear whether MetS could modify the association between cardiac and renal damage. OBJECTIVE: The aim of this study was to assess if the relationship of albumin/creatinine ratio (ACR) and left ventricular mass (LVM) could be independent from MetS in hypertensive overweight/obese patients. METHODS: 180 essential hypertensive and overweight/obese (body mass index [BMI] ≥25 kg/m(2)) patients referred to our Hypertension Centre from January 2006 to April 2009 because of blood pressure (BP) control-related problems were studied. Exclusion criteria were scarce adherence to antihypertensive drug therapy as investigated by the Morisky Medical Adherence Scale (MMAS), heart failure (New York Heart Association III or IV or left ventricular ejection fraction [LVEF] <50%), liver failure, cancer or other systemic severe diseases. MetS was defined according to the National Cholesterol Education Program (USA) Adult Treatment Panel III classification as modified by the American Heart Association. ACR was obtained from first morning urine specimens. Left ventricular dimensions, mass and ejection fraction, were measured by echocardiography following the American Society of Echocardiography recommendations. RESULTS: Patients with microalbuminuria had a 6-fold higher risk for LVH/h(2.7) and 2-fold higher risk for LVH/body surface area (BSA). Univariate linear regression analysis showed a positive relationship between ACR and LVM, expressed both as LVM/h(2.7) or LVM/BSA, as well as a direct correlation between logACR and interventricular diameters and ejection fraction. Regression models including logACR, estimated glomerular filtration rate, BMI, age, hypertension duration, smoking and MetS (as a single variable as well as each single component), showed that only logACR, BMI, hypertension duration and systolic blood pressure (SBP) were independently associated with LVM/h(2.7). CONCLUSION: Along with BP and BMI, albuminuria measured in a morning urine sample as ACR is a valuable low-cost index of cardiac organ damage and increased cardiovascular risk in hypertensive patients independently by MetS. On the other hand, MetS is not an independent risk factor for cardiac damage because it does not seem to add anything more than the sum of each of its components (especially SBP and adiposity indexed by BMI) to the relationship between cardiac and renal subclinical organ damage.

Cannabinoid CB1 receptor expression in relation to visceral adipose depots, endocannabinoid levels, microvascular damage, and the presence of the Cnr1 A3813G variant in humans.

Dysregulation of the endocannabinoid system in the visceral adipose tissue (VAT) is associated with metabolic and cardiovascular complications of obesity. We studied perirenal VAT CB1 receptor expression in relation to anthropometry, VAT area and endocannabinoid levels, kidney microvascular damage (MVDa), and the presence of the CB1 gene A3813G variant, the frequency of which was also evaluated in a large population of obese-hypertensive (OH) patients with or without the metabolic syndrome (MetS). Perirenal VAT and kidney samples were obtained from 30 patients undergoing renal surgery. Total and perirenal VAT areas were determined by computed tomography. CB1 messenger RNA expression and endocannabinoid levels in perirenal VAT were determined by quantitative reverse transcriptase polymerase chain reaction and liquid chromatography-mass spectrometry, respectively. The MVDa was evaluated in healthy portions of kidney cortex. The A3813G alleles were identified by genotyping in these patients and in 280 nondiabetic OH patients (age

Predictive validity of the Identification of Seniors At Risk (ISAR) screening tool in elderly patients presenting to two Italian Emergency Departments.

BACKGROUND AND AIMS: Elderly patients presenting to Emergency Departments (ED) have complex health problems and often undergo adverse outcomes after an ED visit. In Canadian ED, the Identification of Seniors At Risk (ISAR) is useful in screening for these aspects. This study evaluated the predictive validity of ISAR for elderly patients presenting to Italian ED. METHODS: Prospective observational study of a cohort of 200 elderly patients presenting to two urban ED in Ancona (Italy). Identifiers and triage, clinical and social data were collected, and the ISAR was administered. The following single outcomes were considered: early (30-day) and late (6-month) ED revisit, frequent ED return, hospital admission, and functional decline. Composite outcomes were: [1] death, long-term care (LTC) placement, functional decline; [2] the same as [1] plus any ED revisit or hospitalization. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: ISAR was positive for 141 (70.5%) subjects, who had high comorbidity, disability and cognitive impairment. ISAR-positive patients had an OR of 4.77 (95% CI, 2.19-10.42) to undergo composite outcome [1] and of 3.46 (95% CI, 1.68-7.15) to experience composite outcome [2]. ISAR also predicted ED revisit and frequent use, hospitalization and functional decline at 6 months. ISAR was also an independent predictor of 6-month mortality (Hazard Ratio 6.9, 95% CI 1.65-29, p=0.008). CONCLUSIONS: ISAR can be used as a screening test to identify Italian elderly ED patients who have an increased 6-month risk of death, LTC placement, functional decline, ED revisit, or hospitalization.

Altered pattern of cannabinoid type 1 receptor expression in adipose tissue of dysmetabolic and overweight patients.

In overweight patients (OW), the increased peripheral activity of the endocannabinoid system in visceral adipose tissue (VAT) may be mediated by cannabinoid type 1 (CB1) receptor expression. We determined whether CB1 receptor splice variants and messenger RNA (mRNA) levels in perirenal and subcutaneous adipose tissues are associated with obesity and metabolic syndrome (MetS). Gene expression with multiple-primers real-time polymerase chain reaction (TaqMan; Applied Biosystem, Weiterstadt, Germany) was performed to study VAT and paired subcutaneous adipose tissue (SAT) mRNA from 36 consecutive patients undergoing nephrectomy. Cannabinoid type 1A and CB1E mRNAs variants with the longer version of exon 4 were expressed. The CB1 expression in perirenal VAT significantly correlated with body mass index (BMI). Paired subcutaneous/perirenal samples from normal-weight patients (BMI < 25 kg/m(2)) showed higher CB1 expression in SAT (P = .002), whereas in OW (BMI > or = 25 kg/m(2)), the higher CB1 expression was in VAT (P = .038). In unpaired samples, SAT of normal-weight patients had significantly higher CB1 mRNA levels compared with SAT of OW, whereas higher CB1 expression (P = .009) was found in VAT of OW (n = 25). Overweight patients with increased visceral CB1 expression had higher waist circumference (P < .01), insulin (P < .01), and homeostasis model assessment index (P < .01). In addition, patients with the MetS (n = 22) showed higher CB1 expression in perirenal adipose tissues (P = .007). Visceral adipose CB1 expression correlated with BMI. Overweight patients and those with MetS showed a CB1 expression pattern supporting a CB1-mediated overactivity of the endocannabinoid system in human VAT.

A geriatric emergency service for acutely ill elderly patients: pattern of use and comparison with a conventional emergency department in Italy.

The current disease-oriented, episodic model of emergency care does not adequately address the complex needs of older adults presenting to emergency departments (EDs). Dedicated ED facilities with a specific organization (e.g., geriatric EDs (GEDs)) have been advocated. One of the few GED experiences in the world is described and its outcomes compared with those of a conventional ED (CED). In a secondary analysis of a prospective observational cohort of 200 acutely ill elderly patients presenting to two urban EDs in Ancona, Italy, identifiers and triage, clinical, and social data were collected and the following outcomes considered: early (30-day) and late (6-month) ED revisit, frequent ED return, hospital admission, and functional decline. Death, functional decline, any ED revisit and any hospital admission were also considered as a composite outcome. Odds ratios and 95% confidence intervals (CIs) were calculated. Overall, GED patients were older and frailer than CED patients. The two EDs did not differ in terms of early, late, or frequent ED return or in 6-month hospital admission or functional decline. The mortality rate was slightly but significantly lower in the GED patients (hazard ratio=0.47, 95% CI=0.22-0.99, P=.047). The data suggest noninferiority and, indirectly, a slight superiority for the GED system in the acute care of elderly people, supporting the hypothesis that ED facilities specially designed for older adults may provide better care.

Mini Nutritional Assessment (short form) and functional decline in older patients admitted to an acute medical ward.

BACKGROUND AND AIMS: Protein and/or energy malnutrition is common in hospitalized older patients and is associated with poor outcomes. Among recommended nutritional screening tools, contrasting data exist about the usefulness of the Mini Nutritional Assessment Short-Form (MNA-SF). We evaluated whether the MNA-SF, alone or integrated with serum albumin levels, is a reliable predictor of functional decline in older patients. METHODS: We studied 275 elderly patients (mean age 76.5, 60.7% males) admitted to an acute medical ward of a tertiary-care teaching hospital over a 12-month period. In this observational study, we evaluated nutritional status, with the MNA-SF alone or integrated with albumin. Data were collected at admission and related to laboratory and geriatric assessment features, and length of stay (LOS). Functional decline (defined as a loss >or=10% in terms of Barthel Index score at discharge compared with 2 weeks before admission) was considered as outcome. RESULTS: The MNA-SF estimated 46% patients at risk of malnutrition. These subjects had worse clinical features (lower total cholesterol and albumin levels), longer LOS (13.3 vs 11.2 days, p=0.014) and considerable functional decline (OR 4.25, 95% CI 1.83-9.9, p=0.001). Integrating the MNA-SF with albumin values, we obtained an effective instrument to detect older inpatients with protein-energy malnutrition, at higher risk of undergoing functional decline (OR 16.19, 95% CI 4.68-56.03, p<0.0001). CONCLUSIONS: The MNA-SF is a useful screening tool for hospitalized elders at risk of malnutrition. It is associated with poor clinical outcomes and is able to predict functional decline. Together with hypoalbuminemia, it better identifies patients with true protein-energy malnutrition.