MNA® Mini Nutritional Assessment as a nutritional screening tool for hospitalized older adults; rationales and feasibility

The high prevalence of malnutrition in the growing population of older adults makes malnutrition screening critical, especially in hospitalized elderly patients. The aim of our study was to evaluate the use of the MNA® Mini Nutritional Assessment in hospitalized older adults for rapid evaluation of nutritional risk. A prospective cohort study was made of 106 patients 65 years old or older admitted to an internal medicine ward of a tertiary-care teaching hospital to evaluate the use of the short form, or screening phase, of the MNA-SF. In the first 48 hours of admission, the full MNA questionnaire was administered and laboratory tests and a dermatologic evaluation were made. The MNA score showed that 77% of the patients were at risk of malnutrition or were frankly malnourished. Low blood levels of albumin, cholesterol and vitamins A and D showed a statistically significant association with malnutrition or risk of malnutrition. Separate evaluation of the MNA-SF showed that it was accurate, sensitive and had predictive value for the screening process. Routine use of the MNA-SF questionnaire by admission nurses to screen patients is recommended. Patients with MNA-SF scores of 11 or lower should be specifically assessed by the nutritional intervention team.

Effect of laser remelting on the tribological performance of thermal barrier coatings

Gas turbine's efficiency improves as operating temperature is increased. For this reason, metallic components used in turbine engines, for propulsion and power generation, are protected by thermal barrier coatings (TBC). Laser glazing has been used to enhance the oxidation and corrosion resistance of thermally sprayed TBC, but there is no information about the effect of this treatment on the tribological performance. ZrO2(CaO) top coat and NiAIMo bond coating were flame sprayed onto an AlSI 1045 carbon steel. The top coat was laser remelted and a densified ceramic layer was induced in the top surface of the ceramic coating. Both, the as sprayed and the laser remelted top coatings, were formed by cubic ZrO2 with some tetragonal precipitates. The grain size was reduced by the laser treatment. The mechanical properties and the local wear rate were evaluated by depth sensing indentation and scratch tests respectively. The nanoscale wear behaviour was always improved by the laser treatment.

[Cognitive impairment]

Cognitive impairment is common in multiple sclerosis (MS), occurring at all stages of the disease, even at the earliest, and can be a major source of disability, social impairment, and impoverished quality of life. Cognitive dysfunction is mainly focused on working memory, conceptual reasoning, verbal fluency, speed of information processing, attention and executive function. Measures of information-processing speed appear to be the most robust and sensitive markers of cognitive impairment in MS patients. Cognitive testing in MS patients is complex and cognitive screening tests are time- and cost-saving test instruments. A comprehensive and sensitive cognitive test procedure should be administered to detect cognitive dysfunction, and recent studies demonstrate that single, predominantly speed-related cognitive tests may be superior to extensive and time-consuming test batteries in screening cognitive decline. Additional clinical factors, including disease course, fatigue, and affective disturbance, can impact the degree of MS-related cognitive impairment. Despite weak correlation with disease duration and physical disability status, the degree of cognitive impairment in MS has been related to the extent of topographically specific neuronal tissue damage and loss. Numerous studies have applied conventional and quantitative magnetic resonance imaging (MRI) techniques to correlate the profile and degree of cognitive impairment with various MRI-detectable abnormalities. The burden of MRI-visible lesions does not fully account for the degree of MS-related cognitive impairment. Nonconventional MRI findings suggest the extent of subtle tissue damage in normal-appearing white and grey matter to correlate best with the severity of cognitive impairment in MS patients. Structural MRI approaches have recently been extended by functional MRI studies scrutinizing the brain's ability for adaptive functional reorganization in the presence of widespread tissue damage. Cognitive impairment in MS seems to be not simply the result of tissue destruction, but also a balance between tissue destruction, tissue repair, and adaptive functional reorganization. These findings highlight the need to screen for cognitive deficits in MS patients to conduct potential cognitive rehabilitation intervention.

Motor evoked potentials in clinically isolated syndrome suggestive of multiple sclerosis

The aim of the present study was to determine the sensitivity and the profile of motor evoked potentials (MEP) in patients with clinically isolated syndrome (CIS) suggestive of multiple sclerosis (MS). We measured the central motor conduction time (CMCT), amplitude ratio (AR), and surface ratio (SR) in tibialis anterior and first dorsal interosseous muscles in 22 patients with CIS. In 12 patients, the triple stimulation technique (TST) was also performed. AR was abnormal in 50% of patients, CMCT in 18% of patients, and TST in 25% of patients. AR had the highest sub-clinical sensitivity and the best positive predictive value. In the absence of clinical pyramidal signs, an early AR decrease seems to result from demyelination inducing excessive temporal dispersion of the MEP, while in territories with clinical pyramidal signs, it seems to result from conduction failure, which suggests that clinical pyramidal signs may be attributable to conduction failure. This study demonstrates that MEP, especially the AR, is sensitive to motor pathway dysfunction right from the early stages of MS.

Assessment of cortico-spinal tract impairment in multiple system atrophy using transcranial magnetic stimulation

OBJECTIVE

Among Parkinsonian syndromes, pyramidal signs suggesting cortico-spinal impairment are a hallmark of multiple system atrophy (MSA). Although it is crucial to diagnose correctly this disease to choose the appropriate treatment, the available diagnostic criteria lack sensitivity. Cortical excitability patterns assessed by transcranial magnetic stimulation (TMS) do not differentiate Parkinsonian disorders. TMS using triple stimulation technique (TST) accurately detects cortico-spinal impairment. We hypothesized that this technique could detect such impairment in MSA patients.

METHODS

The TST was applied along with single and paired-pulse TMS to 31 patients fulfilling the diagnostic criteria for MSA-P (n=10), MSA-C (n=4), progressive supranuclear palsy (PSP; n=6) and Idiopathic Parkinson's disease (IPD; n=11) and 11 control subjects.

RESULTS

Single and paired-pulse TMS patterns did not differ between any patient group. The TST pattern was abnormal in five MSA-P, one MSA-C and one PSP patients but not in IPD patients or controls. The mean TST ratio for MSA-P (86.6%) was significantly different from IPD (99.1%; p<0.05) whereas ratios for MSA-C (92.1%) and PSP (93.3%) were not different from IPD or controls (99.5%).

CONCLUSIONS

These results suggest that TST is effective to assess cortico-spinal impairment in MSA.

SIGNIFICANCE

TST might be useful for the diagnosis of atypical Parkinsonism.

Prospective clinical and electrophysiological follow-up on a multiple sclerosis population treated with interferon beta-1 a

Objective To analyse transcranial magnetic stimulation (TMS) variables in a prospective six-month follow-up pilot study on patients suffering from relapsing-remitting multiple sclerosis (RRMS), satisfying inclusion criteria for interferon (IFN) beta-1a treatment.

Background So far, no predictive factors are available as to the course of RRMS treated with IFN beta-1 a.

Design/methods Fifteen RRMS patients were studied before (month 0 (M0)) and after IFN beta-1a onset (M3, M6). The parameters analysed were motor functional score (mFS), Expanded Disability Status Scale (EDSS), and TMS variables - central motor conduction time (CMCT) and amplitude ratio (AR).

Results Four of the six patients with no motor signs at inclusion, subsequently showed signs of pyramidal dysfunction. All had abnormal M0_TMS variables. The number of M0_TMS abnormalities per patient was greatest in the group that showed mFS worsening, and was significantly correlated with M6_EDSS. The M0_CMCT was significantly correlated with M6_EDSS. During follow-up, the number of patients with abnormal TMS variables decreased from 12/15 to 4/15, and the total number of abnormalities decreased from 33.3 to 16.7%.

Conclusions TMS variables might be predictive of disease progression. The improvement observed here in the TMS variables may reflect an improvement in MS patients undergoing IFN beta treatment. Multiple Sclerosis 2007; 13: 348-356. http://msj.sagepub.com

Power rather than path dependency? The dynamics of institutional change under health care federalism

Proposals for government decentralization rank high on the political reform agenda of health systems worldwide. Their impact on welfare state performance and change, however, is still under theoretical scrutiny. This article examines the impact of devolution on the construction of the Spanish National Health Service (NHS) in an attempt to shed some light on this debate. Against widespread claims of path dependency, we argue that the specific nature of the devolution model developed in Spain, given the more egalitarian sociopolitical structure that resulted from democratization, fostered policy innovation and institutional change. Consolidation of an NHS system was compatible with some regional diversity and apparently prevented the rise of significant territorial inequalities. The Spanish case also suggests that policy change depends more on the distribution of social power than on institutions. It underlines the key role of financial and knowledge transfers vis-à-vis institutional reforms in effecting social change as well as the potential for state intervention in supporting the development of collective action resources by social groups.

Genetic characterization of Erwinia amylovora strains by amplified fragment length polymorphism

AIMS

Erwinia amylovora is one of the most important pathogens of pear and apple and is subject to strict quarantine regulations worldwide, although its patterns of dispersal are largely unknown. Previous attempts to fingerprint E. amylovora strains by molecular techniques have detected very little polymorphism because of the high genetic homogeneity of this bacterium. Our aim was to establish and test a typing method to quantify genetic diversity among strains of this plant pathogen.

METHODS AND RESULTS

Twenty-two strains from different hosts and geographical locations were examined by PCR fingerprinting with four primers and by amplified fragment length polymorphism (AFLP) with four selected combinations of primers with a single base extension. PCR fingerprinting revealed little polymorphism producing the same amplification patterns for 17 strains, while the combined AFLP patterns yielded 78 polymorphic bands (34% of total bands) and allowed the differentiation of all but two strains. Clustering of strains in the resulting dendrogram was not correlated with host, year or country of isolation, and questions previous genealogies based on PFGE patterns.

CONCLUSIONS

The AFLP technique allowed the detection of an unprecedented number of genetic markers in E. amylovora and proved to be the most useful tool so far for discriminating among strains of this pathogen. The results obtained in this study strongly suggest the occurrence of multiple introductions of the pathogen in Spain and other European countries.

SIGNIFICANCE AND IMPACT OF THE STUDY

A major limitation in understanding the ecology of fire blight is the lack of typing techniques with a high power of discrimination. This study demonstrates the high resolution and the usefulness of the AFLP technique to differentiate among E. amylovora strains.

[Decentralization: part of the health system problem or the solution?]

The greatest change experienced by the Spanish health system in the last two decades has probably been the devolution of power to the autonomous communities composing the Spanish state. This may generate tensions in the status quo and poses questions of whether decentralization of the health system is compatible with a cohesive national health system and whether this devolution of power is part of the problem of the health system or part of its solution. Generalized devolution occurring as rapidly as that produced in Spain (negotiated in slightly less than 6 months, with minimal financial agreements, without explicit legal frameworks in the areas of coordination and development of basic norms, and with a new agreement of general financing of the autonomous communities which possibly contains lacunae, etc.) presents an uncertain panorama. The possible misuse of the wide powers recently transferred to the autonomous communities could easily be used by those who would like to see a restoration of pre-democratic centralism to sow fear of the collapse of the health service as the cornerstone of the welfare state among the general public. The present article briefly addresses these questions.

Evaluation of performance of white blood cell reduction filters: an original flow cytometric method for detection and quantification of cell-derived membrane fragments

BACKGROUND

Contamination of blood products by white blood cells leads to a risk of transmission of infectious agents, particularly abnormal prion protein, the probable causative agent of new-variant Creutzfeldt-Jakob disease. Blood product filtration could reduce this risk, but the filtration systems might generate potentially infectious membrane fragments. We developed an original flow cytometric method that allows the detection and quantification of membrane fragments in filtered products and the evaluation of the quantity of destroyed cells.

METHODS

This method has four technical requirements: cytofluorometric acquisition of forward scatter parameters on a log scale, use of a fluorescent aliphatic reporter molecule (PKH26-GL) to identify membrane fragments, quantification with fluorescent beads, and the drawing up of a standard curve on the basis of cells destroyed by freezing/thawing to generate cell debris (i.e., quantity of membrane fragments measured versus quantity of destroyed cells).

RESULTS AND CONCLUSIONS

This original method can be used to test new filtration devices and it allows optimization of the filtration process or comparison of different filtration systems. We tested the method with three commercial white cell removal filters. We demonstrated that it is possible to evaluate the filter quality, particularly the likelihood of fragment removal during the filtration process.