Patient assessment and feasibility of treatment in older patients with cancer: results from the IN-GHO® Registry.

PURPOSE: Predicting feasibility of treatment in older patients with cancer is a major clinical task. The Initiative Geriatrische Hämatologie und Onkologie (IN-GHO®) registry prospectively collected data on the comprehensive geriatric assessment (CGA), physician's and patient's-self assessment of fitness for treatment, and the course of treatment in patients within a treatment decision aged ≥ 70 years. PATIENTS AND METHODS: The registry included 3169 patients from 93 centres and evaluated clinical course and treatment outcomes 2-3 and 6 months after initial assessment. Fitness for treatment was classified as fit, compromised and frail according to results of a CGA, and in addition by an experienced physician's and by patient's itself. Feasibility of treatment (termed IN-GHO®-FIT) was defined as a composite endpoint, including willingness to undergo the same treatment again in retrospect, no modification or unplanned termination of treatment, and no early mortality (within 90 days). RESULTS: CGA classified 30.0% as fit, 35.8% as compromised, and 34.2% as frail. Physician's and patient's-self assessment classified 61.8%/52.3% as fit, 34.2%/42.4% as compromised, and 3.9%/5.3%, as frail, respectively. Survival status at day 180 was available in 2072 patients, of which 625 (30.2%) had died. After 2-3 months, feasibility of treatment could be assessed in 1984 patients. 62.8% fulfilled IN-GHO®-FIT criteria. Multivariable analysis identified physician's assessment as the single most important item regarding feasibility of treatment. CONCLUSION: Geriatricians were involved in 2% of patients only. Classification of fitness for treatment by CGA, and physician's or patient's-self assessment showed marked discrepancies. For the prediction of feasibility of treatment no single item was superior to physician's assessment. However CGA was not performed by trained geriatricians.

[Challenges of implementing a geriatric trauma network : A regional structure]. / Herausforderung der Implementierung eines Alterstraumanetzwerks : Ein standortübergreifendes Verbundsystem.

BACKGROUND: At present, there is a high percentage and increasing tendency of patients presenting with orthogeriatric injuries. Moreover, significant comorbidities often exist, requiring increased interdisciplinary treatment. These developments have led the German Society of Trauma Surgery, in cooperation with the German Society of Geriatrics, to establish geriatric trauma centers. METHODS: As a conglomerate hospital at two locations, we are cooperating with two external geriatric clinics. In 2015, a geriatric trauma center certification in the form of a conglomerate network structure was agreed upon for the first time in Germany. For this purpose, the requirements for certification were observed. Both structure and organization were defined in a manual according to DIN EN ISO 9001:2015. RESULTS: Between 2008 and 2016, an increase of 70% was seen in geriatric trauma cases in our hospital, with a rise of up to 360% in specific diagnoses. The necessary standards and regulations were compiled and evaluated from our hospitals. After successful certification, improvements were necessary, followed by a planned re-audit. These were prepared by multiprofessional interdisciplinary teams and implemented at all locations. CONCLUSIONS: A network structure can be an alternative to classical cooperation between trauma and geriatric units in one clinic and help reduce possible staffing shortage. Due to the lack of scientific evidence, future evaluations of the geriatric trauma register should reveal whether network structures in geriatric trauma surgery lead to a valid improvement in medical care.

Pneumonia severity, comorbidity and 1-year mortality in predominantly older adults with community-acquired pneumonia: a cohort study.

BACKGROUND: In patients with community-acquired pneumonia (CAP), short-term mortality is largely dependent on pneumonia severity, whereas long-term mortality is considered to depend on comorbidity. However, evidence indicates that severity scores used to assist management decisions at disease onset may also be associated with long-term mortality. Therefore, the objective of the study was to investigate the performance of the pneumonia severity scores CURB-65 and CRB-65 compared to the Charlson Comorbidity Index (CCI) for predicting 1-year mortality in adults discharged from hospital after inpatient treatment for CAP. METHODS: From a single centre, all cases of patients with CAP treated consecutively as inpatients between 2005 and 2009 and surviving at least 30 days after admission were analysed. The patients' vital status was obtained from the relevant local register office. CURB-65, CRB-65 and CCI were compared using receiver operating characteristics (ROC) analysis. RESULTS: Of 498 cases analysed, 106 (21.3%) patients died within 1 year. In univariate analysis, age ≥65 years, nursing home residency, hemiplegia, dementia and congestive heart failure were significantly associated with mortality. CURB-65, CRB-65 and CCI were also all associated with mortality at 1 year. ROC analysis yielded a weak, yet comparable test performance for CURB-65 (AUC and corresponding 95% confidence interval [CI] for risk categories: 0.652 [0.598-0.706]) and CCI (AUC [CI]: 0.631 [0.575-0.688]; for CRB-65 0.621 [0.565-0.677] and 0.590 [0.533-0.646]). CONCLUSIONS: Neither CURB-65 or CRB-65 nor CCI allow excellent discrimination in terms of predicting longer term mortality. However, CURB-65 is significantly associated with long-term mortality and performed equally to the CCI in this respect. This fact may help to identify CAP survivors at higher risk after discharge from hospital.

Short-term mortality of adult inpatients with community-acquired pneumonia: external validation of a modified CURB-65 score.

OBJECTIVE: The management of community-acquired pneumonia (CAP) continues to be a challenge, especially in older people. To enable better risk stratification, a variation of the severity scores CRB-65 and CURB-65, called CURB-age, has been suggested. We compared the association between risk groups as defined by the scores and 30-day mortality for a cohort of mainly older inpatients with CAP. METHODS: We retrospectively analysed data from the CAP database from the years 2005 to 2009 of a single centre in Herne, Germany. Patient characteristics, criteria values within the severity scores CURB-65, CRB-65 and CURB-age, and 30-day mortality were assessed. We compared the association between score points and score-defined risk groups and mortality. Sensitivity and specificity with corresponding 95% CIs were calculated, and receiver operating characteristic (ROC) curve analysis was performed. RESULTS: Data from 559 patients were analysed (mean age 74.1 years, 55.3% male). Mortality at day 30 was 10.9%. CURB-age included more patients in the low-risk category than CRB-65 (195 vs 89), and the patient group had a lower mortality (2.6% vs 3.4%). When compared with CURB-65, CURB-age included slightly fewer patients (195 vs 214) with lower mortality (2.6% vs 4.2%). CURB-age sorted the most patients who died within 30 days into the high-risk CAP group (CURB-age, 32; CURB-65, 28; CRB-65, 9), which had the highest mortality (CURB-age, 26.4%; CURB-65, 19.4%; CRB-65, 21.4%). Advantages of CURB-age categories were depicted through ROC curve analysis (area under the curve 0.73 (95% CI 0.67 to 0.79) for CURB-age categories, 0.67 (95% CI 0.60 to 0.74) for CURB-65 categories, and 0.59 (95% CI 0.52 to 0.66) for CRB-65 categories). CONCLUSIONS: In comparison with CRB-65 and CURB-65, risk stratification as defined by CURB-age showed the closest association with 30-day mortality in our sample. Further prospective studies are needed to assess the potential of CURB-age for better risk prediction, especially in older patients with CAP.

External validation of the CURSI criteria (confusion, urea, respiratory rate and shock index) in adults hospitalised for community-acquired pneumonia.

BACKGROUND: For patients hospitalised due to community-acquired pneumonia (CAP), mortality risk is usually estimated with prognostic scores such as CRB-65 or CURB-65. For elderly patients, a new score referred to as CURSI has been proposed which uses shock index (SI) instead of the blood pressure (B) and age (65) criteria. The new score has not been externally validated to date. METHODS: We used data from a hospital-based CAP registry to compare the ability of CURSI, CURB-65 and CRB-65 to predict mortality at day 30 after hospital admission. Patients were stratified by score points as well as score-point-based risk categories, and mortality for each group was assessed. To compare test performance, receiver-operating characteristic (ROC) curves were constructed, and the areas under the curve (AUROC) were calculated with 95% confidence intervals (CI). RESULTS: We analysed 553 inpatients (45% females, median age 78 years) hospitalised between 2005 and 2009 for CAP. Overall, mortality at day 30 was 11% (59/553). The study sample was characterised by advanced comorbidity (chronic heart failure: 22%, chronic kidney failure: 27%) and functional impairment (nursing home residency: 26%, dementia: 31%). All risk scores were significantly associated with 30-day mortality. The AUROC values with 95% CI using score points for risk prediction were as follows: 0.63 [0.56-0.71] for CRB-65, 0.68 [0.61-0.75] for CURB-65 and 0.68 [0.61-0.75] for CURSI. The CURSI-defined low-risk group (0 or 1 score point) had a higher mortality (8%) than the low-risk groups defined by CURB-65 and CRB-65 (4% and 3%, respectively). Lowering the cut-off for the CURSI-defined low-risk group (0 point only) would lower the mortality to 4%, making it comparable to the CURB-65-defined low-risk group. CONCLUSIONS: In our study, the CURSI-defined low-risk group had a higher 30-day mortality than the low-risk groups defined by CURB-65 and CRB-65. Lowering the cut-off value for the CURSI low-risk group would result in a mortality comparable to the CURB-65-defined low risk group. Even then, however, CURSI does not perform better than the established risk scores.

Falls and EQ-5D rated quality of life in community-dwelling seniors with concurrent chronic diseases: a cross-sectional study.

BACKGROUND: Although recommended for use in studies investigating falls in the elderly, the European Quality of Life Group instrument, EQ-5D, has not been widely used to assess the impact of falls on quality of life. The aim of this study was to investigate the association of single and frequent falls with EQ-5D rated quality of life in a sample of German community-dwelling seniors in primary care suffering a variety of concurrent chronic diseases and conditions. METHODS: In a cross-sectional study, a sample of community-dwelling seniors aged ≥ 72 years was interviewed by means of a standardised telephone interview. According to the number of self-reported falls within twelve months prior to interview, participants were categorised into one of three fall categories: no fall vs. one fall vs. two or more falls within twelve months. EQ-5D values as well as other characteristics were compared across the fall categories. Adjustments for a variety of concurrent chronic diseases and conditions and further variables were made by using multiple linear regression analysis, with EQ-5D being the target variable. RESULTS: In total, 1,792 participants (median age 77 years; 53% female) were analysed. The EQ-5D differed between fall categories. Participants reporting no fall had a mean EQ-5D score of 81.1 (standard deviation [s.d.]: 15.4, median: 78.3), while participants reporting one fall (n = 265; 14.8%) and participants with two or more falls (n = 117; 6.5%) had mean total scores of 77.0 (s.d.: 15.8, median: 78.3; mean difference to participants without a fall: -4.1, p < 0.05) and 72.1 (s.d.: 17.6, median: 72.5; mean difference: -9.0, p < 0.05), respectively. The mean difference between participants with one fall and participants with two or more falls was -4.9 (p < 0.05). Under adjustment for a variety of chronic diseases and conditions, the mean decrease in the total EQ-5D score was about -1.0 score point for one fall and about -2.5 points for two or more falls within twelve months. In quantity, this decrease is comparable to other chronic diseases adjusted for. Among the variables with the greatest negative association with EQ-5D ratings in multivariate analysis were depression and fear of falling. CONCLUSIONS: The findings suggest that falls are negatively associated with EQ-5D rated quality of life independent of a variety of chronic diseases and conditions.

Prevalence of self-reported pain, joint complaints and knee or hip complaints in adults aged ≥ 40 years: a cross-sectional survey in Herne, Germany.

BACKGROUND: Pain and musculoskeletal complaints are among the most common symptoms in the general population. Despite their epidemiological, clinical and health economic importance, prevalence data on pain and musculoskeletal complaints for Germany are scarce. METHODS: A cross-sectional survey of a random sample of citizens of Herne, Germany, aged ≥ 40 years was performed. A detailed self-complete postal questionnaire was used, followed by a short reminder questionnaire and telephone contacts for those not responding. The questionnaire contained 66 items, mainly addressing pain of any site, musculoskeletal complaints of any site and of knee and hip, pain intensities, the Western Ontario MacMaster Universities (WOMAC) index, medication, health care utilization, comorbidities, and quality of life. RESULTS: The response rate was 57.8% (4,527 of 7,828 individuals). Survey participants were on average 1.3 years older, and the proportion of women among responders tended to be greater than in the population sample. There was no age difference between the population sample and 2,221 participants filling out the detailed questionnaire. The following standardized prevalences were assessed: current pain: 59.7%, pain within the past four weeks: 74.5%, current joint complaints: 49.3%, joint complaints within the past four weeks and twelve month: 62.8% and 67.4%, respectively, knee as the site predominantly affected: 30.9%, knee bilateral: 9.7%, hip: 15.2%, hip bilateral: 3.5%, knee and hip: 5.5%. Pain and musculoskeletal complaints were significantly more often reported by women. A typical relationship of pain and joint complaints to age could be found, i.e. increasing prevalences with increasing age categories, with a drop in the highest age groups. In general, pain and joint pain were associated with comorbidity and body mass index as well as quality of life. CONCLUSIONS: Our data confirm findings of other recent national as well as European surveys. The high site specific prevalences of knee and hip complaints underline the necessity to further investigate characteristics and consequences of pain and symptomatic osteoarthritis of these joints in adults in Germany.

A review of the major vascular risk factors related to Alzheimer's disease.

The present review is dedicated to the epidemiology of vascular risk factors proven to play a role in facilitating onset and progression of cognitive impairment. These include hypertension, hypercholesterolemia, diabetes, obesity, atherosclerosis, and cardiac diseases. The targeted, chance-free identification and management of traditional vascular risk factors in midlife is a general public health strategy against the onset of mild to severe cognitive impairment in advanced age. This preventive action must be routinely carried out with outmost awareness by physicians in order to be effective. In advanced age, the individually shaped assessment and management of vascular risk factors assumes particular importance as some of them show a strong age-dependent pattern. The relative strategies with this purpose cannot be separated from a thorough lifestyle anamnesis including nutrition, physical exercise, and cognitive and social activities.

Conflict of evidence: carotenoids and other micronutrients in the prevention and treatment of cognitive impairment.

Cognitive impairment is a common age-related disorder which affects in the stadium and type Alzheimer's Disease (AD) a steadily growing number of patients. AD is not curable and is not being easily diagnosed in its preclinical phase. This work aims at highlighting the complex though promising rationale for the use of selected micronutrients against age-related cognitive impairment and its progression. The advances made in the last decades in both defining the etiopathogenesis of cognitive impairment and in revealing mechanisms of action underlying possible preventive effects of several vitamins and micronutrients--likely related to antioxidant activity and modulation of cellular signaling--is being accompanied by conflicting results of most clinical trials. Therefore, available data do not currently support the use of substances such as carotenoids, polyphenols, vitamin D, curcumin, vitamin E, vitamin C, or lipoic acid in AD prevention and/or treatment. This might be partly due to the fact that cognitive impairment and especially AD are extremely complex disorders. The main obstacle to the inclusion of micronutrients among anticognitive impairment drug strategies, however, is that studies conducted so far are poorly comparable and probably underestimate of the role of vascular damage in age-related cognitive impairment. A possible clinical benefit of these substances in AD is not disproved to date, thus further better designed studies are needed.

Bridging the pathophysiology of Alzheimer's disease with vascular pathology: the feed-back, the feed-forward, and oxidative stress.

Alzheimer's disease (AD) is slowly but steadily undergoing a profound reshaping of the definition and approach caused by the frustrating gap between poorly controlled AD epidemiology and repeated lack of success in finding a cure. The frequently reported and currently accepted role of vascular pathology and vascular risk factors in AD pathophysiology in recent years is one major aspect of this need for a severe adjustment in the modus operandi in AD. A clue into the importance that the interdependence between AD and vascularity has gained in scientific opinion is the large amount of recent reviews, almost reaching that of original papers, on the topic. Far from aiming to meta-analyze all in vitro, in vivo, and ex vivo experiments, animal model research, clinical investigations, and epidemiological surveys conducted so far on the vascular disease-AD axis, this work focus on selected aspects of it in the hope of identifying possible study designs to be applied to the vascular AD patient. Looking over the literature on AD-related vascular pathology, the need also emerges to find the right location of oxidative stress.

Elderly patients with community-acquired pneumonia: optimal treatment strategies.

Community-acquired pneumonia (CAP) is a common infectious disease that still causes substantial morbidity and mortality. Elderly people are frequently affected, and several issues related to care of this condition in the elderly have to be considered. This article reviews current recommendations of guidelines with a special focus on aspects of the care of elderly patients with CAP. The most common pathogen in CAP is still Streptococcus pneumoniae, followed by other pathogens such as Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella species. Antimicrobial resistance is an increasing problem, especially with regard to macrolide-resistant S. pneumoniae and fluoroquinolone-resistant strains. With regard to ß-lactam antibacterials, resistance by H. influenzae and Moraxella catarrhalis is important, as is the emergence of multidrug-resistant Staphylococcus aureus. The main management decisions should be guided by the severity of disease, which can be assessed by validated clinical risk scores such as CURB-65, a tool for measuring the severity of pneumonia based on assessment of confusion, serum urea, respiratory rate and blood pressure in patients aged ≥65 years. For the treatment of low-risk pneumonia, an aminopenicillin such as amoxicillin with or without a ß-lactamase inhibitor is frequently recommended. Monotherapy with macrolides is also possible, although macrolide resistance is of concern. When predisposing factors for special pathogens are present, a ß-lactam antibacterial combined with a ß-lactamase inhibitor, or the combination of a ß-lactam antibacterial, a ß-lactamase inhibitor and a macrolide, may be warranted. If possible, patients who have undergone previous antibacterial therapy should receive drug classes not previously used. For hospitalized patients with non-severe pneumonia, a common recommendation is empirical antibacterial therapy with an aminopenicillin in combination with a ß-lactamase inhibitor, or with fluoroquinolone monotherapy. With proven Legionella pneumonia, a combination of ß-lactams with a fluoroquinolone or a macrolide is beneficial. In severe pneumonia, ureidopenicillins with ß-lactamase inhibitors, broad-spectrum cephalosporins, macrolides and fluoroquinolones are used. A combination of a broad-spectrum ß-lactam antibacterial (e.g. cefotaxime or ceftriaxone), piperacillin/tazobactam and a macrolide is mostly recommended. In patients with a predisposition for Pseudomonas aeruginosa, a combination of piperacillin/tazobactam, cefepime, imipenem or meropenem and levofloxacin or ciprofloxacin is frequently used. Treatment duration of more than 7 days is not generally recommended, except for proven infections with P. aeruginosa, for which 15 days of treatment appears to be appropriate. Further care issues in all hospitalized patients are timely administration of antibacterials, oxygen supply in case of hypoxaemia, and fluid management and dose adjustments according to kidney function. The management of elderly patients with CAP is a challenge. Shifts in antimicrobial resistance and the availability of new antibacterials will change future clinical practice. Studies investigating new methods to detect pathogens, determine the optimal antimicrobial regimen and clarify the duration of treatment may assist in further optimizing the management of elderly patients with CAP.

Association of polymorphisms in CYP19A1 and CYP3A4 genes with lower urinary tract symptoms, prostate volume, uroflow and PSA in a population-based sample.

PURPOSE: The known importance of testosterone for the development of benign prostatic hyperplasia (BPH) prompted us to test the hypothesis whether polymorphisms of two genes (CYP19A1 and CYP3A4) involved in testosterone metabolism are associated with clinical BPH-parameters. METHODS: A random sample of the population-based Herne lower urinary tract symptoms cohort was analysed. All these men underwent a detailed urological work-up. Two polymorphisms in the CYP19A1 gene [rs700518 in exon 4 (A57G); rs10046 at the 3'UTR(C268T)] and one in the 3'UTR of CYP3A4 [rs2740574 (A392G)] were determined by TaqMan assay from genomic DNA of peripheral blood. These polymorphisms were correlated to clinical and laboratory BPH-parameters. RESULTS: A total of 392 men (65.4 ± 7.0 years; 52-79 years) were analysed. Mean International Prostate Symptom Score (IPSS; 7.5), Q (max) (15.4 ml/s), prostate volume (31 ml) and prostate specific antigen (PSA) (1.8 ng/ml) indicated a typical elderly population. Both polymorphisms in the CYP19A1 gene were not correlated to age, IPSS, Q (max), prostate volume and post-void residual volume. Serum PSA was higher in men carrying the heterozygous rs10046 genotype (2.0 ± 0.1 ng/ml) than in those with the CC-genotype (1.7 ± 0.2 ng/ml, P = 0.012). Men carrying one a mutated allele of the CYP3A4 gene had smaller prostates (27.0 ± 2.0 vs. 32 ± 0.8 ml, P = 0.02) and lower PSA levels (1.6 ± 0.3 vs. 1.9 ± 0.1 ng/ml). CONCLUSIONS: The inconsistent associations observed herein and for other gene polymorphisms warrant further studies. In general, the data regarding the association of gene polymorphism to BPH-parameters suggest that this disease is caused by multiple rather than a single genetic variant. A rigorous patient selection based on anatomo-pathological and hormonal profile may possible reduce the number of confounders for future studies thus enabling a more detailed assessment of the association between genetic factors and BPH-parameters.

Prevention of dementia: focus on lifestyle.

The objective of this paper is to summarize current knowledge on the possible advantages of lifestyle interventions, with particular attention to physical fitness, cognitive activity, leisure and social activity as well as nutrition. There is a large amount of published papers providing partial evidence and asserting the need for immediate, appropriate preventive lifestyle measures against dementia and AD development. Nevertheless, there are currently great difficulties in drafting effective guidelines in this field. This depends mainly upon lack of randomized controlled trials assessing benefits versus risks of particular lifestyle interventions strategies. However, due to the rapid increase of dementia burden, lifestyle factors and their amelioration should be already made part of decision making in light of their health-maintaining effects while awaiting for results of well-designed large prospective cohort studies in dementia.

Modulation of cholesterol in midlife affords cognitive advantage during ageing - a role for altered redox balance.

General practitioners, geriatricians, neurologists and health care professionals all over the world will be facing by 2040 the diagnostic, therapeutic and socioeconomic challenges of over 80 million people with dementia. Dementia is one of the most common diseases in the elderly which drastically affects daily life and everyday personal activities, is often associated with behavioural symptoms, personality change and numerous clinical complications and increases the risk for urinary incontinence, hip fracture, and - most markedly - the dependence on nursing care. The costs of care for patients with dementia are therefore immense. Serum cholesterol levels above 6.5 mmol/L are known to be associated with an increased RR of 1.5 and 2.1 to develop Alzheimer's disease, the most common form of dementia, and a reduction of serum cholesterol in midlife is associated with a lowered dementia risk. The aim of this work is to critically discuss some of the main results reported recently in the literature in this respect and to provide the pathophysiological rationale for the control of dyslipidemia in the prevention of dementia onset and progression.

Bone T-scores and functional status: a cross-sectional study on German elderly.

BACKGROUND: We explore the association between bone T-scores, used in osteoporosis diagnosis, and functional status since we hypothesized that bone health can impact elderly functional status and indirectly independence. METHODS: In a cross-sectional study (2005-2006) on community dwelling elderly (> = 75 years) from Herne, Germany we measured bone T-scores with Dual-energy X-ray Absorptiometry, and functional status indexed by five geriatric tests: activities of daily living, instrumental activities of daily living, test of dementia, geriatric depression score and the timed-up-and-go test, and two pooled indexes: raw and standardized. Generalized linear regression was used to determine the relationship between T-scores and functional status. RESULTS: From 3243 addresses, only 632 (19%) completed a clinical visit, of which only 440 (male:female, 243:197) could be included in analysis. T-scores (-0.99, 95% confidence interval [CI], -1.1-0.9) predicted activities of daily living (95.3 CI, 94.5-96.2), instrumental activities of daily living (7.3 CI, 94.5-96.2), and timed-up-and-go test (10.7 CI, 10.0-11.3) (P < = 0.05). Pooled data showed that a unit improvement in T-score improved standardized pooled functional status (15 CI, 14.7-15.3) by 0.41 and the raw (99.4 CI, 97.8-101.0) by 2.27 units. These results were limited due to pooling of different scoring directions, selection bias, and a need to follow-up with evidence testing. CONCLUSIONS: T-scores associated with lower functional status in community-dwelling elderly. Regular screening of osteoporosis as a preventive strategy might help maintain life quality with aging.

[The geriatric assessment]. / Das geriatrische Assessment.

Due to demographic changes there is an increasing number of elderly and old patients with cancer. This group of patients shows a significant heterogeneity and differs from the average young patient. Identification of relevant functional deficits and comorbidities remains crucial for an efficient treatment strategy of this patient group. For this reason, the geriatric assessment has been developed and integrated in daily oncological practice. Within this diagnostic approach oncologists can for example identify elderly fit patients suitable for aggressive treatments or identify at-risk patients for complications. Recent studies have shown that this approach is feasible in daily practice and capable of improving outcome. There is still the need for more specific instruments for different cancers.

C-reactive protein, severity of pneumonia and mortality in elderly, hospitalised patients with community-acquired pneumonia.

BACKGROUND: increasingly, markers of systemic inflammation like C-reactive protein (CRP) levels and white blood count (WBC) are being used for assessing the prognosis of patients with community-acquired pneumonia (CAP). However, their predictive value has not been validated in populations of elderly patients. OBJECTIVE: to evaluate the prognostic value of CRP and WBC in comparison with the CURB score and the pneumonia severity index (PSI) in elderly, hospitalised patients with CAP. METHODS: the charts of all patients, aged 65 years and older, who were consecutively admitted to the Department of Geriatrics, Marienhospital Herne, Germany, for treatment of CAP between January 2001 and September 2005, were reviewed. CRP, WBC, CURB and PSI were analysed in relation to 30-day mortality. RESULTS: in a total of 391 patients, median age 80 years, no association was found between CRP or WBC and mortality. In contrast, the CURB score and PSI were significantly associated with mortality and treatment in the intensive care unit (ICU). CONCLUSION: in elderly, hospitalised patients with CAP, admission CRP and WBC are not predictors of the prognosis.

High fruit and vegetable intake is positively correlated with antioxidant status and cognitive performance in healthy subjects.

A higher daily intake of fruits and vegetables in healthy elderly is associated with an improved antioxidant status in comparison to subjects consuming diets poor in fruits and vegetables, but the impact on cognitive performance is unclear. Healthy community dwellers (45 to 102 years old, n=193) underwent cognitive testing and blood withdrawal for the measurement of antioxidant micronutrients and biomarkers of oxidative stress as well as administration of a food frequency questionnaire to assess the daily intake of fruits and vegetables (high intake HI, low intake LI). Ninety-four subjects of the HI group had significantly higher cognitive test scores, higher levels of carotenoids, alpha- and gamma-tocopherol as well as lower levels of F2 alpha isoprostanes than the 99 subjects of the LI group. Cognitive scores were directly correlated with blood levels of alpha-tocopherol and lycopene and negatively correlated with F2 alpha isoprostanes and protein carbonyls. The results were independent of age, gender, body mass index, education, total cholesterol, LDL- and HDL-cholesterol, triglycerides, and albumin. Healthy subjects of any age with a high daily intake of fruits and vegetables have higher antioxidant levels, lower levels of biomarkers of oxidative stress, and better cognitive performance than healthy subjects of any age consuming low amounts of fruits and vegetables. Modification of nutritional habits aimed at increasing intake of fruits and vegetables should be encouraged to lower prevalence of cognitive impairment in later life.

[Health services research activities in North Rhine-Westphalia. An analysis of the project database health services research NRW]. / Versorgungsforschungsaktivitäten in Nordrhein-Westfalen. Eine Analyse der Projektdatenbank Versorgungsforschung NRW.

BACKGROUND AND PURPOSE: Health services research is gaining increasing importance in the field of public health. To present its activities and findings more clearly, the "Clearingstelle Versorgungsforschung NRW" (clearinghouse health services research North Rhine-Westphalia) has set up a database of projects in the field of health services research in North Rhine-Westphalia. This article is evaluating these projects assigning them to specific medical fields, funding resources, methods of data acquisition and key words. METHODS: In a first step, all institutions and funders in North Rhine-Westphalia acting in the field of health services research have been identified. Those who responded to a standardized questionnaire with a description of their project were included into the database. RESULTS: By the end of May 2008, the project database contained 184 projects. The results demonstrate that health services research activities can be found in all medical fields. Many projects use quantitative as well as qualitative methods. A documentary and secondary data analysis is performed in half of the projects. Concerning the thematic focal point, the present projects show a wide multiplicity. The projects are mainly funded by the ministries of the German Federal Republic, the federal states and the social insurance agencies. In many cases, several institutions are engaged in the funding of one project. CONCLUSION: The evaluation of health services research projects in North Rhine-Westphalia allows a first insight into health services research activities in Germany. The extension of the database and regular analysis of the research activities are considered desirable.

The effect of time-to-surgery on outcome in elderly patients with proximal femoral fractures.

BACKGROUND: Whether reducing time-to-surgery for elderly patients suffering from hip fracture results in better outcomes remains subject to controversial debates. METHODS: As part of a prospective observational study conducted between January 2002 and September 2003 on hip-fracture patients from 268 acute-care hospitals all over Germany, we investigated the relationship of time-to-surgery with frequency of post-operative complications and one-year mortality in elderly patients (age > or =65) with isolated proximal femoral fracture (femoral neck fracture or pertrochanteric femoral fracture). Patients with short (< or =12 h), medium (> 12 h to < or =36 h) and long (> 36 h) times-to-surgery, counting from the time of the fracture event, were compared for patient characteristics, operative procedures, post-operative complications and one-year mortality. RESULTS: Hospital data were available for 2916 hip-fracture patients (mean age (SD) in years: 82.1 (7.4), median age: 82; 79.7% women). Comparison of groups with short (n = 802), medium (n = 1191) and long (n = 923) time-to-surgery revealed statistically significant differences in a few patient characteristics (age, American Society of Anesthesiologists ratings classification and type of admission) and in operative procedures (total hip endoprosthesis, hemi-endoprosthetic implants, other osteosynthetic procedures). However, comparison of these same groups for frequency of postoperative complications revealed only some non-significant associations with certain complications such as post-operative bleeding requiring treatment (early surgery patients) and urinary tract infections (delayed surgery patients). Both unadjusted rates of one-year all-cause mortality (between 18.1% and 20.5%), and the multivariate-adjusted hazard ratios (HR for time-to-surgery: 1.04; p = 0.55) showed no association between mortality and time-to-surgery. CONCLUSION: Although this study found a trend toward more frequent post-operative complications in the longest time-to-surgery group, there was no effect of time-to-surgery on mortality. Shorter time-to-surgery may be associated with somewhat lower rates of post-operative complications such as decubitus ulcers, urinary tract infections, thromboses, pneumonia and cardiovascular events, and with somewhat higher rates of others such as post-operative bleeding or implant complications.