Extracellular proteinases of Candida species pathogenic yeasts.

The increased incidence of severe disseminated infections caused by the opportunistic yeast-like fungi Candida spp. highlights the urgent need for research into the major virulence factors of these pathogens-extracellular aspartic proteinases of the candidapepsin and yapsin families. Classically, these enzymes were considered to be generally destructive factors that damage host tissues and provide nutrients for pathogen propagation. However, in recent decades, novel and more specific functions have been suggested for extracellular candidal proteinases. These include contributions to cell wall maintenance and remodeling, the formation of polymicrobial biofilms, adhesion to external protective barriers of the host, the deregulation of host proteolytic cascades (such as the complement system, blood coagulation and the kallikrein-kinin system), a dysregulated host proteinase-inhibitor balance, the inactivation of host antimicrobial peptides, evasion of immune responses and the induction of inflammatory mediator release from host cells. Only a few of these activities recognized in Candida albicans candidapepsins have been also confirmed in other Candida species, and characterization of Candida glabrata yapsins remains limited.

[The Choosing Wisely Initiative of the German Society of Internal Medicine : Recommendations of the German Society for Endocrinology and the German Society for Geriatrics]. / Die Klug-entscheiden-Initiative der Deutschen Gesellschaft für Innere Medizin : Empfehlungen der Deutschen Gesellschaft für Endokrinologie und der Deutschen Gesellschaft für Geriatrie.

POSITIVE RECOMMENDATIONS: A. After osteoporotic fractures in the elderly, as a rule specific antiosteoporotic therapy should be initiated. a. Osteoporosis as a disease of the elderly should be diagnosed and treated (recommendation of the German Society for Geriatrics). B. All patients with diabetes mellitus should complete a specific diabetes training program when antidiabetic drug medication is initiated. C. In Germany, all pregnant women should be advised to undertake iodine supplementation. D. Endocrine causes of hypertension should be ruled out in younger patients and in patients on multiple antihypertensive drugs. E. All unclear cases of hypercalcemia should be clarified. NEGATIVE RECOMMENDATIONS: A. Testosterone substitution therapy should not be initiated on the basis of only one measurement of a reduced testosterone level without clinical signs and clarification of the underlying cause. B. Imaging procedures should only be used after the existence of hormonal disease has been confirmed. C. Sonographic screening for thyroid disease is not advised in the elderly. D. Long-term therapy with levothyroxine for nodular goiter should be avoided. E. In relevant stress situations hydrocortisone replacement therapy should not be continued without dose adjustment in patients with adrenal or pituitary insufficiency.

Influence of central nervous system-acting drugs on results of cognitive testing in geriatric inpatients.

INTRODUCTION: Growing evidence shows a high correlation between extensive use of central nervous system-acting drugs (CNSADs) in elderly patients and adverse drug reactions (ADRs) such as falls, fractures, and mortality. RESEARCH QUESTION: Are results of cognitive testing with the Mini Mental Status Examination (MMSE) influenced by use of CNSADs? SETTING: Geriatric inpatient service for acute, subacute, and rehabilitation care. METHODS: Secondary combined analysis of two prospective, single-center study cohorts (PROPSYC, 2011 and AGE OUT, 2012) with identical procedure for the MMSE at a tertiary hospital. RESULTS: Overall, 395 patients were included, 144 male (M) and 251 female (F). Mean age was 80.0 ± 8.4 years (M 76.7 ± 9.1, F 81.9 ± 7.3, p = 0.0000). Mean MMSE points were 22.9 ± 4.8 (M 23.2 ± 4.6, F 22.6 ± 5.0, p = 0.211). In total, 258 patients (65.3 %) used drugs with potential adverse cognitive properties. Analgesics with central activity were given to 117 of 395 patients (29.6 %). Low-potency opioids (tramadol hydrochloride, tilidine) were identified in 60 patients and high-potency opioids in 57 patients. Antidepressants were used in 66 patients, benzodiazepines in 26, and hypnotics in 11, while 38 patients received other CNSADs. We only found significant correlations with the results of cognitive testing for sedatives (diazepam and oxazepam, Pearson's r - 0.79, p = 0.05), but not for lorazepam. CONCLUSION: Our analysis shows an influence of sedatives (diazepam and oxazepam, but not lorazepam) on cognitive testing with the MMSE in users of CNSADs.

[Geriatric trauma centers - requirements catalog. An initiative to promote and guarantee the quality of care of elderly trauma patients receiving inpatient care]. / Alterstraumatologisches Zentrum - Anforderungskatalog. Eine Initiative zur Förderung und Sicherung der Qualität der Versorgung alterstraumatologischer Patienten in Deutschland im Bereich der stationären Versorgung.

For the care of the elderly, specific geriatric care facilities in hospitals and specialized rehabilitation centers have been established in the last 20 years throughout Germany. In addition, trauma surgery departments in hospitals and clinics also provide comprehensive care for trauma patients. The present requirements catalog was developed with the aim to ensure the standardization and quality assurance of these care facilities. Thus, the structural basics and, in particular, the structured cooperation between geriatrics and trauma surgery are described and defined in terms of structure, process, and outcome quality. The Bundesverband Geriatrie, the Deutsche Gesellschaft für Geriatrie, and the Deutsche Gesellschaft für Gerontologie und Geriatrie offer documentation for external and internal use and evaluation of the structures and processes for certification of geriatric trauma centers. Prerequisite for certification is to meet the technical requirements defined in the requirements catalogue or documents derived from it, and proof of a quality management system according to ISO 9001.

Design of pharmaceutical products to meet future patient needs requires modification of current development paradigms and business models.

Drugs represent the most common intervention strategy for managing acute and chronic medical conditions. In light of demographic change and the increasing age of patients, the classic model of drug research and development by the pharmaceutical industry and drug prescription by physicians is reaching its limits. Different stakeholders, e.g. industry, regulatory authorities, health insurance systems, physicians etc., have at least partially differing interests regarding the process of healthcare provision. The primary responsibility for the correct handling of medication and adherence to treatment schedules lies with the recipient of a drug-based therapy, i.e. the patient. It is thus necessary to interactively involve elderly patients, as well as the other stakeholders, in the development of medication and medication application devices, and in clinical trials. This approach will provide the basis for developing a strategy that better meets patients' needs, thus resulting in improved adherence to treatment schedules and better therapeutic outcomes.

[Choosing Wisely. A model for the German health care system?]. / Choosing Wisely. Ein Modell für das deutsche Gesundheitswesen?

BACKGROUND: In 2011 the American Board of Internal Medicine (ABIM) started the Choosing Wisely campaign. MATERIALS AND METHODS: The goal was to establish top 5 lists by the medical societies to reduce diagnostic and therapeutic procedures which are not necessary or are potentially harmful, and thereby lower health care costs. The lists contributed by the American Geriatric Society and the American Medical Director Association in 2013 will be discussed. CONCLUSION: At first glance, the idea seems simple, but numerous questions remain. Transferring this process to Germany appears theoretically possible, but various aspects of the health care system should be taken into consideration.

Caring for people with dementia in general hospitals: an education curriculum from the Alzheimer's Society of Lower Saxony, Germany.

Since 2006, the Alzheimer's Society of Lower Saxony, Germany, has been working to improve care and medical treatment for people with cognitive impairment or dementia in general hospitals. An interdisciplinary team systematically worked on the topic for several years and presented results at various symposia. In 2011, a two-stage curriculum was completed and sent in combination with additional training documents to all hospitals and nursing training colleges in Lower Saxony, Germany. The manual comprised a two-step approach with a 14-h training for hospital staff and a 160-h training for qualification of trainers and dementia appointees/chaperones. In addition, the manual included a list of 13 essential points for "dealing with demented people in a general hospital," the information sheet of the German Alzheimer's Society on aspects requiring special attention when a demented person is admitted to a hospital, short descriptions of best practice models, a list of established speakers in the field, and a 30-min film. In 2012, the project won the "Preis für Engagement und Selbsthilfe" of the Hertie Foundation and the "Niedersächsischen Gesundheitspreis" awarded by the Lower Saxon Ministry for Social, Women, Family, and Health Affairs.

[Memento mori: what can be learned from early paintings and woodcuts about death and dying in former times?]. / Memento mori: Was lehren die alten Abbildungen über das Sterben in früheren Zeiten?

What was the impression on death and dying from people living in the 15th century? To answer this question written information is rare on this topic, as few people were able to read at that time, but paintings and early woodcuts may be helpful. Danses macabres (Totentänze) could be seen in Tallinn (formerly Reval), Lübeck, Bern and other places: parts of the original dance macabre still exist in Tallinn, but those in Bern and Lübeck are destroyed; copies however may give a decent impression of their former appearance. At all these dances macabre the death invites persons for a dance: the pope, the Kaiser, the king, the queen, various noblemen and citizens, even young women and small children; to dance with the death meant to die. The death does not dance with any old person. At the time of these dances macabre epidemics and famines were frequent causes of untimely early death.--A booklet Ars moriendi was published about 1470 and taught people how to behave at their hour of death; various devils appear at the deathbed haggling for the soul of the dying person. Thereafter an angel convinces him to trust in god and to resist those false promises of the devil.Nowadays dying is quite different. Usually persons die at very old age and are frequently demented, they die in hospitals, even in intensive care units and possibly without attendance of family members. They may have suffered for a long time and have spent years in nursing homes. Today dying may be just a release from very long suffering.

Bilateral heterotopic ossification after bilateral hip arthroplasty in a geriatric patient.

The case of a geriatric patient with total hip arthroplasty for coxarthrosis and an inpatient fall 12 days after the first operation is reported. Six weeks after the first operation, the patient reported new pain in the area of both hips and thighs. X-ray and scintigraphy confirmed the diagnosis of bilateral heterotopic ossification. NSAID therapy was started, and rapid improvement was observed. At discharge, the patient was able to walk with aids in- and outside. At the 12-month follow-up, x-ray control showed Brooker state 3 for the right and 4 for the left hip. Walking ability did not change during follow-up.

[Pneumonia in the elderly: results of quality improvement program for a geriatric department in Lower Saxony 2006-2009]. / Pneumonie im Alter: Ergebnisse des Moduls Ambulant erworbene Pneumonie in Niedersachsen für eine geriatrische Klinik 2006-2009.

BACKGROUND: Is the time to diagnosis and to start antibiotic therapy a major factor contributing to the outcome in geriatric patients? METHODS: In 2006, a program for documentation and improvement for diagnostic and therapeutic procedures in patients with community-acquired pneumonia was introduced in German hospitals. The analyses were performed centrally by an independent board. SETTING: Tertiary geriatric department with 70 beds for acute care and rehabilitation in a hospital, also including a department of neurology and neurological rehabilitation. RESULTS: In Lower Saxony (LS), 81,853 patients were treated between 2006-2009 in our geriatric department (GD). In LS, 55.3% of the population was male, while 45.2% of the patients in the GD were male (p=0.063). Throughout an age of 79 years, the distribution was equal; however in the age groups 80-89 years (LS vs GD: 32.3 vs 47.6%) and >90 years (LS vs GD: 10.2 vs 15.5%, p<0.001) there were a higher proportion of male patients in the GD. The proportion of male nursing home patients was 46.8% vs 24.3%, hospital or rehabilitation unit 6.2% vs 40.5%, and status of confinement to bed was 47% vs 35.1% (LS vs GD, p<0.001). Delirium caused by pneumonia occurred in 24.4% vs 9.3% and a status of chronic delirium (dementia) was assessed by 75.6% vs. 90.7% of all cases (LS vs GD, p=0.021). The distribution about the risk classes 1/2/3 of the CRB-65 score was 14.9/76.9/8.2% in LS and 3.6/89.3/7.1% in the GD (p=0.011). The time to starting antibiotics (no therapy, <4, 4-8, and >8 h) was 2.2/83.0/7.6/7.2% in LS and 15.4/47.4/10.3/26.9% in GD patients (p<0.001). Overall mortality rates did not differ significantly (LS 14.6% vs GD 11.9%, p=0.53). CONCLUSIONS: Patients in the GD were older and more functionally dependent. The distribution of the risk index CRB-65 shows that these patients were at higher risk, were more often cognitively impaired (not caused by pneumonia), and time to starting antibiotics was longer. However, none of these differences had an influence on total mortality. The results are limited by the number of patients, potential differences of the treatment groups, and the quality of data in general as a result of a quality improvement program.

[Chronic inflammation and biomarkers. Is ageing an expression of chronic inflammation?]. / Chronische Inflammation und Biomarker. Ist Altern ein Ausdruck von chronischer Entzündung?

Ageing shows a high interindividual and intraindividual variability. Subclinical and clinical cardiovascular diseases accelerate the ageing process in part and in total. This leads to the idea that ageing is a result of a chronic inflammation process and to the term "inflammageing". A variety of biomarkers (e.g. C-reactive protein, interleukin-6, tumor necrosis factor alpha, fibrinogen, albumin and serum amyloid A) are described in this context. Furthermore there is a relationship to changes in the immune system across the lifespan (immunosenescence), viral infections, the occurrence of markers of oxidative stress and genetic changes. At this point in time the role for determining ageing and its use as a prognostic tool seems to be impossible. Whether inflammageing is a valid model for describing the ageing process or is the consequence of other mechanisms needs further discussion.

[Chronic cardiac insufficiency in the elderly]. / Chronische Herzinsuffizienz im Alter.

The incidence of chronic heart failure rises with increasing age as does the proportion of diastolic dysfunction in comparison to heart failure with reduced systolic ejection fraction. Symptoms are less specific, such as fatigue, which makes a diagnosis more difficult but classification and diagnostic work-up are the same as in younger patients. Regarding therapy there is less data because the typical study population does not include geriatric patients with multimorbidity. Nevertheless ACE inhibitors, angiotensin receptor blockers, aldosterone antagonists, diuretics and digoxin should also be used in geriatric patients considering indications and contraindications and especially interactions with co-morbidities and other prescribed medication on an individual basis. The numbers of patients above the age of 75 years receiving heart surgery is increasing. Current scores often overestimate the risk of an operation even though after individual stratification surgical and interventional procedures can be performed with low risk.