Comprehensive Multimorbidity Patterns in Older Patients Are Associated with Quality Indicators of Medication-MoPIM Cohort Study.

Multimorbidity is increasing and poses a challenge to the clinical management of patients with multiple conditions and drug prescriptions. The objectives of this work are to evaluate if multimorbidity patterns are associated with quality indicators of medication: potentially inappropriate prescribing (PIP) or adverse drug reactions (ADRs). A multicentre prospective cohort study was conducted including 740 older (≥65 years) patients hospitalised due to chronic pathology exacerbation. Sociodemographic, clinical and medication related variables (polypharmacy, PIP according to STOPP/START criteria, ADRs) were collected. Bivariate analyses were performed comparing previously identified multimorbidity clusters (osteoarticular, psychogeriatric, minor chronic disease, cardiorespiratory) to presence, number or specific types of PIP or ADRs. Significant associations were found in all clusters. The osteoarticular cluster presented the highest prevalence of PIP (94.9%) and ADRs (48.2%), mostly related to anxiolytics and antihypertensives, followed by the minor chronic disease cluster, associated with ADRs caused by antihypertensives and insulin. The psychogeriatric cluster presented PIP and ADRs of neuroleptics and the cardiorespiratory cluster indicators were better overall. In conclusion, the associations that were found reinforce the existence of multimorbidity patterns and support specific medication review actions according to each patient profile. Thus, determining the relationship between multimorbidity profiles and quality indicators of medication could help optimise healthcare processes. Trial registration number: NCT02830425.

Prognostic value of muscle mass assessed by DEXA in elderly hospitalized patients.

OBJECTIVES: To analyze the prognostic value of lean mass measured by DEXA and to compare it with lean muscle mass assessed by anthropometrics, calf circumference, subjective assessment and with physical muscle function tests in elderly hospitalized patients. METHODS: We study 187 hospitalized patients aged ≥65 years. We assessed nutrition by anthropometrics, mid arm muscle area, triceps skinfold and calf circumference, by subjective nutritional assessment and by DEXA, lean and fat mass and bone mineral density (BMD); muscle function by handgrip strength, gait speed, standing balance and stand-up test; disability and activities of daily living and the clinical frailty score; and comorbidity by Charlson index. Outcomes were assessed by mortality at 100 days and long-term follow up. RESULTS: Male sex showed higher comorbidity and mortality although females were older, with decreased muscle mass and function, disabled and frailer. Long term mortality was also related to decreased lean mass evaluated by subjective assessment, midarm anthropometry, calf circumference and DEXA (appendicular lean and fat mass and BMD); muscle function impairment assessed by gait speed, standing balance and stand-up test; frailty; disability and comorbidity. Variables with long term independent predictive value were comorbidity, inability to perform any of the muscle function tests: gait speed, standing balance and stand-up; subjective nutritional score, appendicular lean mass under the 10th percentile and male sex. CONCLUSIONS: Females are older and frailer but with lower comorbidity; they showed a better survival. The best predictive mortality factor was comorbidity, but DEXA appendicular lean mass under the 10th percentile showed an independent and high predictive value on mortality.

Prognostic value of physical function tests and muscle mass in elderly hospitalized patients. A prospective observational study.

AIM: To determine the prognostic value for mortality of physical function tests, muscle mass loss, disability and frailty in elderly hospitalized patients. METHODS: We prospectively included 298 hospitalized patients aged >60 years (152 men and 146 women). We assessed comorbidity using the Charlson Comorbidity Index; nutrition by body mass index, midarm muscle area and subjective nutritional score; physical muscle function by handgrip strength, gait speed, standing balance and stand up test; disability using the Barthel test and activities of daily living; frailty by the clinical frailty scale and Fried frailty index; and cognitive impairment by the Pfeiffer test. We assessed 100-day and long-term mortality. RESULTS: We found a high prevalence of malnutrition, comorbidity, cognitive impairment, physical function impairment, disability and frailty. Mortality at 100 days was 15.1%, with a long-term median survival of 989 days. Mortality was significantly related to age, comorbidity, nutritional status, physical function, disability and frailty. Serum vitamin D3 levels were not related to mortality. Independent prognostic value for long-term mortality was shown by: (i) incapacity to carry out any of the walking, stand up and standing balance tests; (ii) male sex; (iii) aged >80 years; (iv) impaired handgrip strength or gait speed; (v) Charlson Comorbidity Index ≥1; and (6) impaired muscle mass of subjective nutritional score. CONCLUSIONS: In elderly hospitalized patients, there is an important role of muscle regarding prognosis, mainly related to physical function, but also and independently regarding muscle mass. Geriatr Gerontol Int 2018; 18: 57-64.

Pulmonary thromboembolism in a patient with May-Thurner syndrome: a case report

A 41-year-old woman was admitted to the emergency room with symptoms compatible with deep vein thrombosis affecting the left lower extremity and pulmonary thromboembolism. A CT scan was consistent with pulmonary emboli and thrombosis of the iliac veins extending to the inferior vena cava, which persisted even after correct systemic fibrinolytic therapy. For this reason, a venography was performed and local thrombolysis was administered. Venography revealed a compression of the left common iliac vein caused by the right common iliac artery, so that the patient was diagnosed with May-Thurner syndrome. The clinical features of this anatomical condition and sometimes lethal clinical syndrome are discussed

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Vitamin D, vascular calcification and mortality among alcoholics.

AIMS: To analyze the relationship between low vitamin D levels and mortality among alcoholics. METHODS: One hundred twenty-eight alcoholic patients admitted to our hospital were followed up as outpatients. Nutritional status was evaluated measuring percentages of fat and lean mass in different body compartments. RESULTS: Lower vitamin D levels were observed in patients with worse liver function. Vitamin D was lower in patients with lower total lean mass (Z = 2.8, P = 0.005), but it was not related to fat mass. There was a significant trend to higher long-term mortality among non-cirrhotics with vitamin D levels below 30 ng/ml, although Cox's regression model revealed that only Child score and age were independently related to mortality. CONCLUSION: Vitamin D deficiency is common among alcoholic patients and is associated with low lean mass and liver dysfunction. Among non-cirrhotics, serum vitamin D levels below 30 ng/ml are associated with a greater long-term mortality.

Prognostic value of physical function tests: hand grip strength and six-minute walking test in elderly hospitalized patients.

To discern if physical function test are better mortality predictors than muscle mass in elderly hospitalized patients, we analyzed the prognostic value of muscle mass malnutrition and compared it with physical muscle function tests, including the six-minute walking test (6 MWT) and hand grip strength. We included the ankle brachial index (ABI) to assess arterial disease, related to muscle atrophy due to hypoperfusion. We also analyzed the relationship of ABI with malnutrition, physical function tests and survival. We studied 310 hospitalized patients older than 60 years. To assess nutritional status, we determined BMI, triceps skinfold and mid-arm muscle area; we performed a subjective nutritional assessment; and evaluated the degree of inflammatory stress. We assessed physical function by hand grip strength and 6 MWT. We evaluated arterial disease by ABI. Forty-one patients died during hospitalization; 269 were discharged and followed for a mean 808 days, reaching a mortality of 49%. Muscle malnutrition was frequent and was related to mortality, but the best predictors were physical function tests: inability to perform the 6 MWT and low handgrip strength. Function tests were closely related to each other and correlated with nutritional data. Reduced ABI was related to impaired nutritional status, physical function tests and mortality.

Iron and proinflammatory cytokines in chronic hepatitis C virus infection.

Steatohepatitis is a common finding in chronic hepatitis C virus (HCV) infection. As in other forms of steatohepatitis, oxidative damage may play an outstanding role. However, there are conflicting results relative to the role of iron on hepatic lipogenesis. Proinflammatory cytokines up-regulate ferritin expression, probably reflecting a defensive mechanism against increased oxidative stress, capable to open haem ring and release reactive iron. On the contrary, some adipokines, such as adiponectin, are associated with low ferritin levels. The aim of this study is to analyse the relationships of the amount of liver steatosis with serum iron, transferrin and ferritin as well as with proinflammatory cytokines, such as tumour necrosis factor (TNF)-α and interleukin (IL)-6, and adiponectin levels. We included 82 HCV infected patients and assessed the amount of liver fat by histomorphometry and its relationships with serum iron, ferritin and transferrin, adiponectin and TNF-α and IL-6. Liver steatosis was observed in 67 patients out of 82; in the remaining 15 patients, no steatosis at all was found. Patients with steatosis showed significantly higher serum ferritin levels than patients without steatosis (Z = 2.14; p = 0.032). When patients were classified in quartiles according to the intensity of steatosis, we observed that both TNF-α (KW = 10.6; p = 0.014) and IL-6 (KW = 15.2; p = 0.002) were significantly different among the four groups. Patients with more intense steatosis (highest quartile) showed the highest TNF-α and IL-6 values. Patients with severe hepatitis had higher levels of serum iron than patients with mild to moderate hepatitis. Serum iron also showed a correlation with the proportion of fibrosis (ρ = 0.30; p = 0.007). Serum iron levels are related with biochemical and histological parameters derived from liver inflammation in HCV-associated liver disease. Serum ferritin is higher among those with intense steatosis and also shows a (non-significant) trend to be associated with the more severe forms of hepatitis.