[Geriatric ultrasound : Prospective evaluation of ultrasound as extended screening in acute geriatric patients]

BACKGROUND

The aim of this study was to evaluate ultrasound as a routinely used procedure and extended physical examination in geriatric patients in acute care.

METHODS

Prospective study of 86 patients using ultrasound as a screening examination (abdomen, basal sections of the thorax, thyroid glands) under comparative use of a hand-held ultrasound device (HHUSD) and a high-end ultrasound (HEUS = gold standard).

RESULTS

In 20/86 (23.2%) clinically relevant findings with therapeutic consequences were found (pleural effusion, urinary retention, choledocholithiasis metatases, colon tumor). In 22/86 (25.6%) patients, additional questions existed besides the screening indication: tumor search (9.3%), anemia (5.8%), liver value elevation (5.8%), dyspnea (5.8%), splenic pathologies (2.3%), weight loss (1.2%), infectious focus (1.2%), diarrhea (1.2%), intra-abdominal hematoma (1.1%), abdominal aortic aneurysm (1.2%). The most common sonographic findings included: cholecystolithiasis (32.6%); right pleural effusion (31.4%), thyroid nodules (30.2%), renal cysts (27.9%), and fatty liver (26.7%). There were significant differences in sizing between HHUSD and HEUS (kidneys, pancreatic corpus and pancreatic caudal diameters, portal vein, left hepatic vein) without diagnostic relevance.

CONCLUSION

The extended screening by ultrasound provided important answers to classical questions in geriatrics (e.g. urinary retention, volume deficiency/pleural effusion) in many cases. The new findings had therapeutic consequences in one fifth of the patients. The HHUSD can be used in screening.

Does the identification of seniors at risk (ISAR) score effectively select geriatric patients on emergency admission?

The number of older patients admitted to emergency departments (ED) increases continuously. The Identification of Seniors at Risk (ISAR) score is currently recommended to screen patients in German ED, but its appropriateness is being criticized. ISAR scores and clinical characteristics from 98 emergency admissions (EA), 80 from acute geriatrics (AG) and 89 from a geriatric rehabilitation (GR) unit were compared retrospectively. No significant differences were found between groups, being the ISAR score positive in 87.7% of EA, 94.9% of AG and 94.4% of GR cases. None of positively identified geriatric patients in the EA was transferred to the geriatric ward of competence. EA patients showed significantly higher number of functional impairments (p = 0.001) and higher BI score (p < 0.0001) compared to AG and GR groups. A higher ISAR score threshold and additional functional information might be needed to better select patients in need of prompt treatment by a geriatric team.

BedMachine v3: Complete Bed Topography and Ocean Bathymetry Mapping of Greenland From Multibeam Echo Sounding Combined With Mass Conservation

Greenland's bed topography is a primary control on ice flow, grounding line migration, calving dynamics, and subglacial drainage. Moreover, fjord bathymetry regulates the penetration of warm Atlantic water (AW) that rapidly melts and undercuts Greenland's marine-terminating glaciers. Here we present a new compilation of Greenland bed topography that assimilates seafloor bathymetry and ice thickness data through a mass conservation approach. A new 150 m horizontal resolution bed topography/bathymetric map of Greenland is constructed with seamless transitions at the ice/ocean interface, yielding major improvements over previous data sets, particularly in the marine-terminating sectors of northwest and southeast Greenland. Our map reveals that the total sea level potential of the Greenland ice sheet is 7.42 ± 0.05 m, which is 7 cm greater than previous estimates. Furthermore, it explains recent calving front response of numerous outlet glaciers and reveals new pathways by which AW can access glaciers with marine-based basins, thereby highlighting sectors of Greenland that are most vulnerable to future oceanic forcing.

What does delirium cost? An economic evaluation of hyperactive delirium

BACKGROUND

Demographic changes have resulted in an increase in the number of older (> 75 years) multimorbid patients in clinics. In addition to the primary acute diagnoses that lead to hospitalization, this group of patients often has cognitive dysfunctions, such as delirium. According to clinical experience, delirium patients are more time-consuming for clinicians and their function is often poor. The costs caused by delirium patients are currently unknown. In the present study, a retrospective examination of a database was carried out to calculate the costs that arise during the clinical treatment of documented delirium patients.

SETTING AND METHODS

The purpose of this retrospective analysis was to collect information recorded by nursing personnel trained in the treatment of delirium and information from a manual documentation matrix for additional time expenditure. In the database analysis anonymous data of previously discharged patients for a time window of 3 months were analyzed. Documented additional expenditure for patients with hyperactive delirium at hospitalization were analyzed by personnel. Material costs, the duration of hospitalization by main diagnosis and age clusters during hospitalization until discharge were also examined. The analysis was performed in a hospital with internal wards.

RESULTS

Data for 82 hyperactive delirium patients were examined and an average of approximately 240 min of additional personnel expenditure for these patients was found. These patients were approximately 10 years older (p < 0.01) and were hospitalized for an average of 4.2 days longer (p < 0.01) than non-delirium patients. Hyperactive delirium usually developed within the first 5 days of hospitalization and lasted 1.6 days on average. Patients for whom hyperactive delirium was detected early were hospitalized for significantly less time than those for whom it was detected late (6.85 versus 13.61 days, p = 0.002). Additionally, calculated personnel and material costs, including costs affecting the hospitalization period, amounted to approximately 1200 € per hyperactive delirium patient. This corresponds to approximately 0.3 CMP (casemix points) per patient.

CONCLUSION

The calculations of personnel and material costs and duration of hospitalization in patients with hyperactive delirium demonstrated significant additional costs. Early routine detection of delirium can be achieved through training and this approach leads to a shortening of the hospitalization period and lower costs.

ESPEN Guidelines on Enteral Nutrition: Geriatrics

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Effects of cyclophosphamide and ifosfamide on neuroblastoma cells before and after activation by microsomes

Cyclophosphamide (CP) and Ifosfamide (IF) are of great importance in the therapy of neuroblastoma (NB). They are prodrugs which have to be activated by microsomes in order to become active compounds. We established a test system which allowed the activation of CP and IF by liver microsomes in the presence of NB cells. The data from these experiments showed that neuroblastoma cells (SK-N-SH, SK-N-LO and IMR-5) were unable to activate CP and IF, but in the presence of rat liver microsomes considerable cytotoxicity was achieved, similar to those of the preactivated derivatives maphosphamide (MP) and 4-hydroxy-ifosfamide (4-OH-IF). Compared to other compounds the final metabolite acrolein contributes significantly to the cytotoxicity of CP and IF, obviously through significant lowering of the glutathione levels in the cells. The incubation system as described allows the rapid determination of the cytotoxicity of CP and IF in the simultaneous presence of microsomes. The results show great differences in the sensibility of NB cells toCP and IF.