Predicting the outcome of long-term care by clinical and functional indices: the role of nutritional status

In elderly subjects, past researches have already underlined the role of nutritional status as a basic factor able to influence the prognosis either in acute wards or in rehabilitation and long-term care settings. Aim of the study is that of retrospectively verify, through a multivariate analysis, the factors able to condition mortality in long-term care, paying particular attention to the nutritional status.

METHODS

The survey included 513 patients aged more than 65 years admitted to a long-term care unit during a three years period. Exitus within the first three months of hospitalization was considered the outcome variable, while baseline functional, cognitive, clinical and nutritional status were considered the independent variables eventually related to mortality.

RESULTS

The univariate analysis found that some variables were significantly correlated with the outcome: comorbidity, ADL, cognitive status, pressure sores, albumin, transferrin, CRP, mucoprotein, cholesterol, cholinesterase, MAMC and MNA. The predictive value of the block model of the logistic regression analysis was 77.9% (specificity = 85.3%, sensitivity = 63.9%). With the forward stepwise analysis only MNA, cholinesterase, CRP and mucoprotein were considered in the final model. In this case the predictive value of the model was 79.3% (specificity = 84.6%, sensitivity = 69.46%).

Obesity in the elderly

Obesity is a prevalent health disease among the elderly as it contributes to the early onset of chronic morbidity and functional impairment and is also related to premature mortality. The prevalence of sarcopenic-obesity increases too with age in each sex leading to a significantly higher prevalence of physical impairment and disability, as well as higher prevalence of metabolic syndrome. We observe a natural phenomenon (ageing) and a complex world-wide illness (obesity) that should not be merely treated as the sum of the treatments for the elderly and for the obese. The balance between the potential benefits of treatment interventions, reducing premature morbidity and mortality, and the impact on quality of life in old age may be different from young and adult age in case of obesity and need to be seriously considered.

Multidisciplinary approach to obesity

Obesity, associated with morbidity and mortality, is a complex disorder, characterised by an increase in fat mass (FM). Most authors agree in considering essential an integrated treatment made up of nutritional intervention, physical reconditioning programme and cognitive-behavioural psychotherapy. However, the feasibility is problematic and data in literature confirming the validity of this approach are poor.

AIM

To verify the efficacy of a multidimensional approach (Nutritional Psycho-Physical Reconditioning - NPPR) in obesity treatment.

METHODS

All patients admitted from June 2002 to June 2004 (464 subjects) ranged from 18 to 65 years old, with a body mass index (BMI) >30 kg/m2 were included in the programme. After the nutritional status evaluation a standard dietetic treatment (group N) or an integrated and multidisciplinary obesity treatment (group NPPR) was proposed.

RESULTS

In group NPPR treatment duration was significantly higher (142.6+/-26 vs 48.6+/-55 days - p=0.000), while the drop-out amount was definitely lower (5.5 vs 54.4%; p=0.000). Weight loss compared to the initial weight and the difference between initial and final FM resulted significantly higher in group NNPR. Subjects in NPPR obtained a higher increase in the distance covered in a 6-minute walk test (59.9+/-19 vs 40.5+/-17 m; p=0.04) and in muscular strength. State and trait anxiety, mood and quality of life scores improved in NPPR subjects while remained substantially stable in group N.

CONCLUSIONS

An integrated approach to obesity is the way to be pursued in order to obtain important and at least short-term results.

Purpura fulminans during meningococcal sepsis treated with Drotrecogin alpha. A clinical case

A male patient, 29 years old, was admitted to our unit with purpura fulminans, coagulation deficiency, renal failure and subsequent septic shock accompanied by respiratory insufficiency in the absence of meningeal signs. The serum levels of endogenous protein C, ATIII and calcium were well below the norm. The bacteriological examination revealed the presence of gram-negative diplococci. The onset of adult respiratory distress syndrome (ARDS) revealed aa early complication of the meningococcal sepsis. Forty-eight hours after being admitted, the recombinant protein C infusion was started at a dose of 24 microg/kg/h for the duration of 96 h. The skin lesions regressed, starting from the ecchymosis and the edema of the face, trunk and auricular pavilions. A week after the onset of the symptomatology the chest X-ray appeared clear, the renal function had normalised, and the signs of shock had disappeared.

[Quality of reawakening and dismissal after anesthesia with various techniques for minor surgical intervention. Clinical and medico-legal aspects]

Different drug combinations were compared in order to assess the quality of anesthesiological control, tolerability and the speed of reawakening and recovery of self-sufficiency in 60 patients undergoing minor surgery. Propofol, combined with fentanyl and N2O due to its inadequate analgesic cover, showed a quickness of action with scarse side-effects, prompt reawakening and rapid recovery of deambulatory self-sufficiency in comparison to the associations of thiopentonefentanyl and thiopentone-isoflurane, thus indicating its preferential use in short surgical operations which can be carried out under a day hospital regimen. In addition, some medico-legal aspects of dimissional of recent developments regarding professional responsibility.