Prevalence, pathophysiology, health consequences and treatment options of obesity in the elderly: a guideline.

The prevalence of obesity is rising progressively, even among older age groups. By the year 2030-2035 over 20% of the adult US population and over 25% of the Europeans will be aged 65 years and older. The predicted prevalence of obesity in Americans, 60 years and older was 37% in 2010. The predicted prevalence of obesity in Europe in 2015 varies between 20 and 30% dependent on the model used. This means 20.9 million obese 60+ people in the USA in 2010 and 32 million obese elders in 2015 in the EU. Although cut-off values of BMI, waist circumference and percentages of fat mass have not been defined for the elderly (nor for the elderly of different ethnicity), it is clear from several meta-analyses that mortality and morbidity associated with overweight and obesity only increases at a BMI above 30 kg/m(2). Thus, treatment should only be offered to patients who are obese rather than overweight and who also have functional impairments, metabolic complications or obesity-related diseases, that can benefit from weight loss. The weight loss therapy should aim to minimize muscle and bone loss but also vigilance as regards the development of sarcopenic obesity - a combination of an unhealthy excess of body fat with a detrimental loss of muscle and fat-free mass including bone - is important in the elderly, who are vulnerable to this outcome. Life-style intervention should be the first step and consists of a diet with a 500 kcal (2.1 MJ) energy deficit and an adequate intake of protein of high biological quality together with calcium and vitamin D, behavioural therapy and multi-component exercise. Multi-component exercise includes flexibility training, balance training, aerobic exercise and resistance training. The adherence rate in most studies is around 75%. Knowledge of constraints and modulators of physical inactivity should be of help to engage the elderly in physical activity. The role of pharmacotherapy and bariatric surgery in the elderly is largely unknown as in most studies people aged 65 years and older have been excluded.

Influence of the quality of nursing on the duration of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease.

OBJECTIVE: To evaluate the influence of nursing on the duration of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease. DESIGN: Data were collected prospectively over a 1-yr period (study year) and compared with previously collected prospective data recorded in our chronic obstructive pulmonary disease database during a 5-yr period. SETTING: The medical intensive care unit (ICU) of a university hospital. PATIENTS: Eighty-seven patients with chronic obstructive pulmonary disease. Fifteen patients had chronic obstructive pulmonary disease that required mechanical ventilation for acute exacerbation of their disease (study year), and 72 were patients with chronic obstructive pulmonary disease from the previously collected data. INTERVENTIONS: The ICU course (duration of mechanical ventilation, mortality) was recorded, as well as several respiratory parameters (pulmonary function tests and arterial blood gases in stable conditions, and nutritional status), and they were compared with an "index of nursing." MEASUREMENTS AND MAIN RESULTS: We developed an "index of nursing", comparing the effective workforce of the nurses (number and qualifications) with the ideal workforce required by the number of patients and the severity of their diseases. A value of 1.0 represented a perfect match between the needed and the effectively present nurses, whereas a lesser value signified a diminished available workforce. This index was compared with the complications and duration of weaning from mechanical ventilation. During the first 5 yrs, the duration of mechanical ventilation increased progressively from 7.3 +/- 8.0 to 38.2 +/- 25.8 days (p = .006). A significant inverse correlation between the duration of mechanical ventilation and the nursing index (p = .025) was found. In the sixth comparative year, the number of nurses increased (nursing index = 1.05) and the duration of mechanical ventilation decreased to 9.9 +/- 13 days (p < .001, yr 5 vs. yr 6). CONCLUSIONS: The quality of nursing appears to be a measurable and critical factor in the weaning from mechanical ventilation of patients with chronic obstructive pulmonary disease. Below a threshold in the available workforce of ICU nurses, the weaning duration of patients with chronic obstructive pulmonary disease increases dramatically. Therefore, very close attention should be given to the education and number of ICU nurses.

No consistent association between processes-of-care and health-related quality of life among patients with diabetes : a missing link?

PURPOSE: Health-related quality of life (HRQoL) is considered a representative outcome in the evaluation of chronic disease management initiatives emphasizing patient-centered care. We evaluated the association between receipt of processes-of-care (PoC) for diabetes and HRQoL. METHODS: This cross-sectional study used self-reported data from non-institutionalized adults with diabetes in a Swiss canton. Outcomes were the physical/mental composites of the short form health survey 12 (SF-12) physical composite score, mental composite score (PCS, MCS) and the Audit of Diabetes-Dependent Quality of Life (ADDQoL). Main exposure variables were receipt of six PoC for diabetes in the past 12 months, and the Patient Assessment of Chronic Illness Care (PACIC) score. We performed linear regressions to examine the association between PoC, PACIC and the three composites of HRQoL. RESULTS: Mean age of the 519 patients was 64.5 years (SD 11.3); 60% were male, 87% reported type 2 or undetermined diabetes and 48% had diabetes for over 10 years. Mean HRQoL scores were SF-12 PCS: 43.4 (SD 10.5), SF-12 MCS: 47.0 (SD 11.2) and ADDQoL: -1.6 (SD 1.6). In adjusted models including all six PoC simultaneously, receipt of influenza vaccine was associated with lower ADDQoL (β=-0.4, p≤0.01) and foot examination was negatively associated with SF-12 PCS (β=-1.8, p≤0.05). There was no association or trend towards a negative association when these PoC were reported as combined measures. PACIC score was associated only with the SF-12 MCS (β=1.6, p≤0.05). CONCLUSIONS: PoC for diabetes did not show a consistent association with HRQoL in a cross-sectional analysis. This may represent an effect lag time between time of process received and health-related quality of life. Further research is needed to study this complex phenomenon.

Diabetic patients who report receiving processes of diabetic care do not express a better quality of life

Background: Chronic disease management initiatives emphasize patient-centered care, and quality of life (QoL) is increasingly considered a representative outcome in that context. In this study we evaluated the association between receipt of processes of diabetic care and QoL. Methods: This cross-sectional population-based study (2011) used self-reported data from non-institutionalized, adult diabetics, recruited from randomly selected community pharmacies in Vaud. Outcomes included the physical and mental composites of the SF-36 (PCS, MCS) and the disease-specific Audit of Diabetes-Dependent QoL (ADDQoL). Main exposure variables were receipt of six diabetes processes-of care in the past 12 months. We also evaluated whether the association between care received and QoL was congruent with the chronic care model, when assessed by the Patient Assessment of Chronic Illness Care (PACIC). We used linear regressions to examine the association between process measures and the three composites of health-related QoL. Analyses were adjusted for age, gender, socioeconomic status, living companion, BMI, alcohol, smoking, physical activity, co-morbidities and diabetes mellitus (DM) characteristics (type, insulin use, complications, duration). Results: Mean age of the 519 diabetic patients was 64.4 years (SD 11.3), 60% were male and 73% had a living companion; 87% reported type 2 DM, half of respondents required insulin treatment, 48% had at least one DM complication, and 48% had DM over 10 years. Crude overall mean QoL scores were PCS: 43.4 (SD 10.5), MCS: 47.0 (SD 11.2) and ADDQoL: -1.56 (SD 1.6). In bivariate analyses, patients who received the influenza vaccine versus those who did not, had lower ADDQoL and PCS scores; there were no other indicator differences. In adjusted models including all processes, receipt of influenza vaccine was associated with lower ADDQoL (β= - 0.41, p=.01); there were no other associations between process indicators and QoL composites. There was no process association even when these were reported as combined measures of processes of care. PACIC score was associated only with the MCS (β= 1.57, p=.004). Conclusions: Process indicators for diabetes care did not show an association with QoL. This may represent an effect lag time between time of process received and quality of life; or that treatment may be related with inconvenience and patient worry. Further research is needed to explore these unexpected findings.

Comprehensive assessment of patients in palliative care: a descriptive study utilizing the INTERMED.

Documentation in palliative care is often restricted to medical and sociodemographic information, and the assessment of physical and psychological symptoms or the quality of life. In order to overcome the lack of comprehensive information, we have evaluated the utility of the INTERMED-a biopsychosocial assessment method to document integrated information of patients' needs-in 82 consecutive patients for whom a palliative care consultation was requested. Results confirm the biopsychosocial heterogeneity of the sample, and the importance of integrated information to clinical, scientific, educational, and health care policy agendas. The INTERMED could become a useful method to tailor interdisciplinary interventions based on comprehensive patient needs assessment.

Nouvelles options dans le traitement de l'incontinence ano-rectale [New options in the treatment of ano-rectal incontinence]

Ano-rectal incontinence is known to affect about 2% of the population. Main risk factors are traumatic delivery and previous anal surgery. All patients should have a trial of conservative treatment. Patients with major external anal sphincter defect have a 70 to 80% improvement of their symptoms after an overlap sphincter repair Unfortunately, these results deteriorate over time. Sacral nerve modulation improves continence and quality of life in 75 to 100% of patients with various aetiologies. In case of idiopathic internal sphincter degeneration, sphincter augmentation with bulking agents seems to be the least expensive option.

Experience of meaning in life in bereaved informal caregivers of palliative care patients.

PURPOSE: Providing care for terminally ill family members places an enormous burden on informal caregivers. Meaning in life (MiL) may be a protective factor, but is jeopardised in caregiving and bereavement. This study evaluates the following questions: To what extent do bereaved informal caregivers of palliative care (PC) patients experience meaning in their lives? What differences emerge in carers compared to the general German population? How does MiL relate to well-being in former caregivers? METHODS: Eighty-four bereaved PC caregivers completed the Schedule for Meaning in Life Evaluation, the Brief Symptom Inventory, the WHOQOL-BREF, a single-item numerical rating scale of quality of life, and the Satisfaction with Life Scale. The experience of MiL of bereaved caregivers was compared to a representative population sample (n=977). RESULTS: The overall MiL fulfillment of bereaved caregivers (69 % female, age 55.5 ± 12.9 years) was significantly lower than in the general population (68.5 ± 19.2 vs. 83.3 ± 14, p<.001), as was the overall importance ascribed to their meaning framework (76.6 ± 13.6 vs. 85.6 ± 12.3, p< .001). PC caregivers are far more likely to list friends, leisure, nature/animals, and altruism. Higher MiL was correlated with better life satisfaction and quality of life. CONCLUSION: Coping with the loss of a loved one is associated with changes in MiL framework and considerably impairs a carer's experience of MiL fulfillment. Individual MiL is associated with well-being in PC caregivers during early bereavement. Specific interventions for carers targeted at meaning reconstruction during palliative care and bereavement are needed to help individuals regain a sense of meaning and purpose.

The role of vectors in the epidemiology of avian malaria

Studies on host-parasite relationships have commonly reported that parasitized hosts undergo changes in their behavioural and life history traits. How do these changes affect the fitness of the hosts? What are the ecological and evolutionary drivers of these changes? These open questions are crucial to predict the parasite spread amongst hosts. Surprisingly, mosquito vectors of diseases to humans and animals have long been seen as passive parasite transporters, being unaffected by the infection though they also function as hosts. Natural parasite-vector interactions are therefore poorly documented in the literature. In this thesis, we seek to address the role of wild vectors in the epidemiology of avian Plasmodium, the etiological agents of malaria in birds. We first conducted avian malaria surveys in field-caught mosquitoes to identify the natural vectors in our temperate study area. We report that ornithophilic Culex pipiens primarily act as a vector for Plasmodium vaughani in spring, this parasite species being progressively replaced by P. relictum along with the season. Season-related factors may thus shape the mosquitoes' vectorial capacity. We then used experimental approaches to determine the effect of avian malaria on wild, naturally infected C. pipiens. We show that infected mosquitoes incur unavoidable physiological costs associated with parasite exploitation, these costs being expressed as a reduced survival under nutritionally stressed conditions only. These results are of significant importance for the epidemiology of avian malaria since seasonal changes in climate may likely influence food quality and quantity available to the mosquitoes. The host-selection preferences of the vectors with respect to the malaria-infection status of their bird hosts largely determine the disease spreading. In a second laboratory experiment, we thus offered wild C. pipiens the opportunity to choose between uninfected and naturally infected great tits, Parus major. We show that host-seeking mosquitoes have innate orientation preferences for uninfected birds. This suggests that avian malaria parasites exert strong selective pressures on their vectors, pushing them to evolve anti-parasite behaviours. We lastly investigated the links between malaria-associated symptoms in birds and resulting attractiveness to the mosquitoes. We show that experimentally malaria-infected canaries, Serinus canaria, suffer severe haematocrit reduction at peak parasitaemia and reduced basal metabolic rate later in the course of the infection. However, no links between infection and bird attractiveness to the mosquitoes were shown in an experiment using canaries as live bait for mosquito trap in the field. These links may have been masked by confounding environmental factors. Using a system where the vectors, parasites and hosts co-occur in sympatry, this thesis illustrates that vectors are not always Plasmodium permissive, which opposes to the traditional view that malaria parasites should have little effect on their vectors. The way that the vectors respond to the parasite threat is largely determined by the environmental conditions. This may have major implications for the epidemiology of avian malaria. - Les études portant sur les relations hôtes-parasites mentionnent souvent que les hôtes parasités subissent des modifications de leurs traits d'histoire de vie ou bien comportementaux. Comment ces changements affectent-ils la valeur sélective des hôtes et celle de leurs parasites ? Quels sont les déterminants de ces modifications ? Ces questions sont d'un grand intérêt en épidémiologie. Pour autant, les moustiques vecteurs de maladies infectieuses ont longtemps été perçus comme de simples transporteurs de parasites, n'étant pas affectés par ces derniers. Cette thèse porte sur le rôle des vecteurs dans l'épidémiologie des Plasmodium aviaires, agents étiologiques de la malaria chez les oiseaux. Dans le but d'identifier les vecteurs naturels de malaria aviaire dans notre zone d'étude, nous avons tout d'abord collecté des moustiques sur le terrain, puis déterminé leur statut infectieux. Nous rapportons que les moustiques Culex pipiens sont principalement impliqués dans la transmission de Plasmodium vaughani au printemps, cette espèce de parasite étant progressivement remplacée par P. relictum au fil de la saison de transmission. Nous avons ensuite conduit une expérience visant à déterminer l'effet de la malaria aviaire sur des C. pipiens sauvages, naturellement infectés. Nous montrons que des coûts sont associés à l'infection pour les moustiques. Ces coûts occasionnent une diminution de la survie des vecteurs seulement lorsque ceux-ci sont privés de ressources nutritionnelles. Des changements saisonniers de climats pourraient affecter la quantité et la qualité des ressources disponibles pour les vecteurs et donc, leur aptitude à transmettre l'infection. Les traits comportementaux des moustiques vecteurs, tels que la recherche et le choix d'un hôte pour se nourrir, sont d'une importance majeure pour la dispersion de la malaria. Pour cela, nous avons offert à des C. pipiens sauvages l'opportunité de choisir simultanément entre une mésange charbonnière (Parus major) saine et une autre naturellement infectée. Nous montrons que les moustiques s'orientent préférentiellement vers des mésanges saines. Les Plasmodium aviaires exerceraient donc de fortes pressions de sélection sur leurs vecteurs, favorisant ainsi l'évolution de comportements d'évitement des parasites. Enfin nous avons cherché à identifier de potentiels liens entre symptômes de l'infection malarique chez les oiseaux et attractivité de ces derniers pour les moustiques. Nous montrons que des canaris (Serinus canaria) expérimentalement infectés sont fortement anémiés au moment du pic infectieux et que leur métabolisme basai diminue plus tard au cours de l'infection. Toutefois, aucun lien entre le statut infectieux et l'attractivité des canaris pour les moustiques n'a pu être montré lors d'une expérience réalisée en nature. Il se peut que ces liens aient été masqués par des facteurs environnementaux confondants. Dans son ensemble, cette thèse illustre que, contrairement aux idées reçues, les vecteurs de malaria aviaire ne sont pas toujours permissifs avec leurs parasites. L'environnement apparaît aussi comme un facteur déterminant dans la réponse des vecteurs face à la menace d'infection malarique. Cela pourrait fortement affecter l'épidémiologie de la malaria aviaire.

Impact of case management on frequent users quality of life : a randomized controlled trial

BACKGROUND: Frequent emergency department users represent a small number of patients but account for a large number of emergency department visits. They should be a focus because they are often vulnerable patients with many risk factors affecting their quality of life (QoL). Case management interventions have resulted in a significant decrease in emergency department visits, but association with QoL has not been assessed. One aim of our study was to examine to what extent an interdisciplinary case management intervention, compared to standard emergency care, improved frequent emergency department users' QoL. METHODS: Data are part of a randomized, controlled trial designed to improve frequent emergency department users' QoL and use of health-care resources at the Lausanne University Hospital, Switzerland. In total, 250 frequent emergency department users (≥5 attendances during the previous 12 months; ≥ 18 years of age) were interviewed between May 2012 and July 2013. Following an assessment focused on social characteristics; social, mental, and somatic determinants of health; risk behaviors; health care use; and QoL, participants were randomly assigned to the control or the intervention group (n=125 in each group). The final sample included 194 participants (20 deaths, 36 dropouts, n=96 in the intervention group, n=99 in the control group). Participants in the intervention group received a case management intervention by an interdisciplinary, mobile team in addition to standard emergency care. The case management intervention involved four nurses and a physician who provided counseling and assistance concerning social determinants of health, substance-use disorders, and access to the health-care system.

Eosinophilic oesophagitis: relationship of quality of life with clinical, endoscopic and histological activity.

BACKGROUND: Knowledge about determinants of quality of life (QoL) in eosinophilic oesophagitis (EoO) patients helps to identify patients at risk of experiencing poor QoL and to tailor therapeutic interventions accordingly. AIM: To evaluate the impact of symptom severity, endoscopic and histological activity on EoE-specific QoL in adult EoE patients. METHODS: Ninety-eight adult EoE patients were prospectively included (64% male, median age 39 years). Patients completed two validated instruments to assess EoE-specific QoL (EoO-QoL-A) and symptom severity (adult EoE activity index patient-reported outcome) and then underwent esophagogastroduodenoscopy with biopsy sampling. Physicians reported standardised information on EoE-associated endoscopic and histological alterations. The Spearman's rank correlation coefficient was calculated to determine the relationship between QoL and symptom severity. Linear regression and analysis of variance was used to quantify the extent to which variations in severity of EoE symptoms, endoscopic and histological findings explain variations in QoL. RESULTS: Quality of life strongly correlated with symptom severity (r = 0.610, P < 0.001). While the variation in severity of symptoms, endoscopic and histological findings alone explained 38%, 35% and 22% of the variability in EoE-related QoL, respectively, these together explained 60% of variation. Symptom severity explained 18-35% of the variation in each of the five QoL subscale scores. CONCLUSIONS: Eosinophilic oesophagitis symptom severity and biological disease activity determine QoL in adult patients with eosinophilic oesophagitis. Therefore, reduction in both eosinophilic oesophagitis symptoms as well as biological disease activity is essential for improvement of QoL in adult patients. Clinicaltrials.gov number, NCT00939263.

Health-Related Quality of Life of Young Adults Treated with Recombinant Human Growth Hormone during Childhood.

BACKGROUND: Since recombinant human growth hormone (rhGH) became available in 1985, the spectrum of indications has broadened and the number of treated patients increased. However, long-term health-related quality of life (HRQoL) after childhood rhGH treatment has rarely been documented. We assessed HRQoL and its determinants in young adults treated with rhGH during childhood. METHODOLOGY/PRINCIPAL FINDINGS: For this study, we retrospectively identified former rhGH patients in 11 centers of paediatric endocrinology, including university hospitals and private practices. We sent a questionnaire to all patients treated with rhGH for any diagnosis, who were older than 18 years, and who resided in Switzerland at time of the survey. Three hundred participants (58% of 514 eligible) returned the questionnaire. Mean age was 23 years; 56% were women; 43% had isolated growth hormone deficiency, or idiopathic short stature; 43% had associated diseases or syndromes, and 14% had growth hormone deficiency after childhood cancer. Swiss siblings of childhood cancer survivors and the German norm population served as comparison groups. HRQoL was assessed using the Short Form-36. We found that the Physical Component Summary of healthy patients with isolated growth hormone deficiency or idiopathic short stature resembled that of the control group (53.8 vs. 54.9). Patients with associated diseases or syndromes scored slightly lower (52.5), and former cancer patients scored lowest (42.6). The Mental Component Summary was similar for all groups. Lower Physical Component Summary was associated with lower educational level (coeff. -1.9). Final height was not associated with HRQoL. CONCLUSIONS/SIGNIFICANCE: In conclusion, HRQoL after treatment with rhGH in childhood depended mainly on the underlying indication for rhGH treatment. Patients with isolated growth hormone deficiency/idiopathic short stature or patients with associated diseases or syndromes had HRQoL comparable to peers. Patients with growth hormone deficiency after childhood cancer were at high risk for lower HRQoL. This reflects the general impaired health of this vulnerable group, which needs long-term follow-up.

Estimation of reference curves for the urinary steroid metabolome in the first year of life in healthy children : Tracing the complexity of human postnatal steroidogenesis.

CONTEXT: Complex steroid disorders such as P450 oxidoreductase deficiency or apparent cortisone reductase deficiency may be recognized by steroid profiling using chromatographic mass spectrometric methods. These methods are highly specific and sensitive, and provide a complete spectrum of steroid metabolites in a single measurement of one sample which makes them superior to immunoassays. The steroid metabolome during the fetal-neonatal transition is characterized by (a) the metabolites of the fetal-placental unit at birth, (b) the fetal adrenal androgens until its involution 3-6 months postnatally, and (c) the steroid metabolites produced by the developing endocrine organs. All these developmental events change the steroid metabolome in an age- and sex-dependent manner during the first year of life. OBJECTIVE: The aim of this study was to provide normative values for the urinary steroid metabolome of healthy newborns at short time intervals in the first year of life. METHODS: We conducted a prospective, longitudinal study to measure 67 urinary steroid metabolites in 21 male and 22 female term healthy newborn infants at 13 time-points from week 1 to week 49 of life. Urine samples were collected from newborn infants before discharge from hospital and from healthy infants at home. Steroid metabolites were measured by gas chromatography-mass spectrometry (GC-MS) and steroid concentrations corrected for urinary creatinine excretion were calculated. RESULTS: 61 steroids showed age and 15 steroids sex specificity. Highest urinary steroid concentrations were found in both sexes for progesterone derivatives, in particular 20α-DH-5α-DH-progesterone, and for highly polar 6α-hydroxylated glucocorticoids. The steroids peaked at week 3 and decreased by ∼80% at week 25 in both sexes. The decline of progestins, androgens and estrogens was more pronounced than of glucocorticoids whereas the excretion of corticosterone and its metabolites and of mineralocorticoids remained constant during the first year of life. CONCLUSION: The urinary steroid profile changes dramatically during the first year of life and correlates with the physiologic developmental changes during the fetal-neonatal transition. Thus detailed normative data during this time period permit the use of steroid profiling as a powerful diagnostic tool.