Compliance of energy-dense, small volume oral nutritional supplements in the daily clinical practice on a geriatric ward--an observational study.

INTRODUCTION: Compliance is important in optimizing the clinical effectiveness of oral nutritional supplements (ONS). Small volume, energy-dense ONS (ED-ONS; ≥ 2 kcal/ml) have been shown to improve compliance in clinical trial settings. However, data from clinical practice is still lacking. The aim of the present study was to evaluate the effect of ED-ONS on the compliance in an observational set-up to obtain data from daily clinical practice on a geriatric ward. METHODS: Geriatric inpatients, undernourished or at risk of undernutrition received two servings of either ED-ONS (125 ml, 2.4 kcal/ml: Nutridrink Compact Energy, Nutricia) or a standard ONS (S-ONS; 200 ml, 1.5 kcal/ml: Nutridrink) as part of their daily routine care. Patients were allocated to a group according to availability of beds and placement on the ward. Compliance (kcal/day and % of prescribed volume) was assessed by weighing returned bottles. Data were analyzed via Mixed Model for Repeated Measures. RESULTS: Forty-seven patients received ED-ONS, and 61 patients received S-ONS. Compliance was significantly higher with ED-ONS in geriatric inpatients compared to S-ONS ( 378 ± 14.0 kcal/day vs. 337 ± 13.6 kcal/day (mean ± SEM), p = 0.039, 63.0 ± 2.34% vs. 56.2 ± 2.26%, p = 0.039). Moreover, a trend (p=0.078) was observed towards an increasing difference in compliance over time. CONCLUSION: This study shows that compliance to ED-ONS is significantly better than to S-ONS in daily clinical practice. Although small, the difference in compliance seems to increase over time, suggesting clinical relevance with longer treatment.

The nutritional status of Dutch elderly patients with Parkinson's disease.

OBJECTIVES: To assess the prevalence of (risk of) undernutrition in Dutch elder Parkinson's disease patients as well as it's risk factors. DESIGN: Observational cross-sectional study. SETTING: An outpatient clinic at the department Neurology of Medical Centre Leeuwarden, a large teaching hospital. PARTICIPANTS: 102 outpatients with Parkinson's disease aged 65 years and older were recruited. MEASUREMENTS: Data regarding various aspects of undernutrition including socio-demographic aspect, disease characterisitics, nutritional status, appetite and overall-physical and psychological functioning were collected. RESULTS: Undernutrition was diagnosed in 2.0% and 20.5% of the patients were categorized as being at risk of undernutrition. Care dependency and appetite were the two risk factors with the highest predictive value for an unfavorable nutritional status. CONCLUSION: Of Dutch elderly patients with Parkinson's Disease 22.5% had an unfavourable nutritional status. Dependency and appetite were the two risk factors with the highest predictive value fort his outcome. Because undernutrition can be regarded as a geriatric syndrome a comprehensive nutritional assessment should be done followed by nutritional interventions next to interventions focused on the risk factors. Further studies are needed to evaluate these interventions.

Nutritional status of community-dwelling elderly with newly diagnosed Alzheimer's disease: prevalence of malnutrition and the relation of various factors to nutritional status.

OBJECTIVES: To determine the prevalence of malnutrition and its relation to various factors in community-dwelling elderly with newly diagnosed Alzheimer's disease (AD). DESIGN: Retrospective cross-sectional study. SETTING: Memory clinic in a rural part of the Netherlands. PARTICIPANTS: 312 Community-dwelling AD patients, aged 65 years or older, were included. MEASUREMENTS: At the time the diagnosis AD was made, socio-demographic characteristics and data on nutritional status (Mini Nutritional Assessment (MNA)), cognitive function (Mini Mental State Examination (MMSE), Cambridge Cognitive Examination (Camcog)), functional status (Interview for Deterioration in Daily Living Activities in Dementia (IDDD), Barthel Index (BI)) and behaviour (Revised Memory and Behaviour Problems Checklist (RMBPC)) were assessed. Characteristics of well-nourished patients (MNA score >23.5) were compared to characteristics of patients at risk of malnutrition (MNA score 17-23.5). Linear regression analysis was performed to assess the effect of various factors on nutritional status. RESULTS: The prevalence of malnutrition was 0% and 14.1% was at risk of malnutrition. AD patients at risk of malnutrition were more impaired in basic and complex daily functioning than well-nourished AD patients (median IDDD score 41.5 [25th -75th percentile 38.8-48.0] versus median IDDD score 40.0 [25th -75th percentile 37.0-43.0], p = 0.028). The degree of impairment in basic and complex daily functioning (IDDD) was independently related to nutritional status (MNA) (p = 0.001, B = -0.062). CONCLUSION: One in seven community-dwelling elderly with newly diagnosed AD is at risk of malnutrition. The degree of impairment in daily functioning is independently related to nutritional status. Therefore, assessment of the nutritional status should be included in the comprehensive assessment of AD patients. The relation between daily functioning, nutritional status and AD warrants further investigation.

Effect of long-term treatment with galantamine on weight of patients with Alzheimer's dementia.

OBJECTIVES: There is discussion about the effect of cholinesterase inhibitors (CERs) on weight of patients with Alzheimer's disease (AD). Given the adverse outcomes of weight loss in AD patients, it is important to establish the effect of CERs on weight. This study aimed tot assess the long-term effect of galantamine on weight of AD patients. DESIGN, SETTING AND PARTICIPANTS: This longitudinal study was performed at a large memory clinic in the North of the Netherlands. During the period 2002 to 2010, 303 community-dwelling AD patients, aged 65 years or older who started using a cholinesterase inhibitor (CER), were included. MEASUREMENTS: Socio-demographic characteristics and data on comorbidity, number of medications, type and dosage of CER, use of care, cognitive function, behaviour and nutritional status (weight, Body Mass Index (BMI)) were recorded at the time the diagnosis AD was made and at subsequent outpatient clinic visits. The Generalized Estimating Equations (GEE) model was used to determine the effect of galantamine of 16 mg and 24 mg on weight. The effect of galantamine in a dose of 16 and 24 mg was investigated because the other groups (rivastigmine, galantamine 8 mg) were too small to determine the effect on weight by GEE analysis. Donepezil is not available in the Netherlands. RESULTS: The median follow-up time between the moment patients started using a CER (T0) and the 1st visit was 6 months (n=300); between T0 and the 2nd visit 13 months (n=212); between T0 and the 3rd visit 25 months (n=117) and between T0 and the 4th visit 37 months (n=58). Galantamine 16 mg and 24 mg, corrected for age, gender, social status, informal care, professional care, comorbidity, number of medications, cognition, behaviour and appetite, had no effect on weight (p > 0.05). Male patients had a higher average weight compared to female patients (p=0.000, B=8.333). Patients without an informal caregiver (p=0.01, B=-3.697) or partner (p=0.042, B=-3.197) had a lower average weight compared to patients with an informal caregiver or partner. CONCLUSION: Weight loss in AD patients should not be attributed to long-term treatment with galantamine. This is in accordance with the French guideline. If AD patients are losing weight, other causes, including insufficient care, should be investigated.

[Diagnostic image (161). A woman suffering from abdominal pain, sickness and belching. Thoracic herniation of the stomach]. / Diagnose in beeld (161). Een vrouw met buikpijn, misselijkheid en opboeren. Thoracale hernia van de maag.

A 20-year-old woman presented with abdominal pain, sickness and belching due to thoracic herniation of the stomach.

How to diagnose cardiac tamponade.

Malignant pericardial effusion is a potentially fatal complication of malignancy unless recognised and treated promptly. Patients with this condition are often difficult to diagnose. Physical examination, chest radiography and electrocardiography have poor diagnostic values in identification of patients with pericardial effusion. Echocardiography, which allows rapid confirmation of the presence of an effusion and precise assessment of its haemodynamic impact, is the gold standard for diagnosis.

[Acute acalculous cholecystitis: not only in the intensive care department]. / Acute acalculeuze cholecystitis; ook buiten de intensive care.

In two men aged 65 and 40 years with abdominal pain, the diagnosis 'acute acalculous cholecystitis' (AAC) could be reached only after exploratory laparotomy. The first patient was initially admitted to the coronary-care department because of known atherosclerotic vascular disease; he died a few days after the operation due to sepsis. The second patient recovered satisfactorily after admission to intensive care because of haemodynamic instability. AAC is an illness with a non-specific clinical presentation and incomplete radiologic imaging. AAC is more frequently seen in outpatients than in acutely ill inpatients, especially in older male patients who have atherosclerotic vascular disease. Diagnostic and therapeutic delay leads to gangrene, empyema and perforation, resulting in a high mortality. To improve the outcome, a high and early index of suspicion is needed. Hepatobiliary scintigraphy should be included in the diagnostic pathway.

[Clinical thinking and decision making in daily practice. An elderly man with hyponatremia]. / Klinisch denken en beslissen in de praktijk. Een oude man met hyponatriëmie.

An 88-year-old man presented with nausea and vomiting. Recently a cutaneous B-cell lymphoma had been diagnosed on his right cheek. Laboratory investigation showed hyponatraemia. Fluid restriction was started, based on the diagnosis of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). However the hyponatraemia persisted and a diagnosis of 'reset osmostat' was made. CT of the abdomen revealed slight bilateral adrenal enlargement, which was interpreted as adrenal incidentaloma. No other localisation of the lymphoma, besides that on the right cheek, was seen. Although the symptoms initially disappeared, they recurred and were quickly followed by hypotension. The patient died. Post-mortem examination showed bilateral destruction of the adrenal glands due to lymphoma. The correct diagnosis was Addison's disease. This case shows that diseases do not always present with all the classical symptoms, and that it is important to consider test characteristics of diagnostic tests and to judge investigations in the context of the other clinical findings.

Delirium after interleukin-2 and alpha-interferon therapy for renal cell carcinoma.

A 55-year-old man receiving alpha-interferon and interleukin-2 therapy for renal cell carcinoma presented with seizures and delirium. A CT-scan of the cerebrum did not reveal any disorder. Both alpha-interferon and interleukin-2 were stopped. Treatment with steroids led to complete regression of central nervous system symptomatology. We emphasize the importance of ruling out iatrogenesis in patients treated with alpha-interferon and/or interleukin-2 who display neuropsychiatric symptoms.

Disseminated intravascular coagulation as an unusual presentation of an Epstein-Barr virus infection.

Epstein-Barr viral (EBV)-infection usually presents as fever, sore throat, fatigue, lymphadenopathy and atypical lymphocytosis. We describe a patient with disseminated intravascular coagulation as the presenting symptom caused by a primary EBV infection.

A randomised, multicentre study of ceftriaxone versus standard therapy in the treatment of lower respiratory tract infections.

In this study the efficacy and cost-effectiveness of i.v. ceftriaxone 1 g once daily (CTX) was compared with standard i.v. antibiotic treatment (STD) for lower respiratory tract infections (LRTI). STD was given according to the guidelines of the American Thoracic Society and consisted of either cefuroxime 1500 mg three times daily (q8h), amoxicillin/clavulanic acid 1200 mg q8h or ceftriaxone 2 g once daily; each with or without a macrolide. After a minimum of 5 days i.v. therapy, patients could be switched to oral therapy. One hundred patients were enrolled in the study; 52 patients received CTX and 48 STD. Groups were comparable with respect to demographic and baseline characteristics. Seventy patients had a confirmed diagnosis of pneumonia. Twenty-nine patients had a severe type I exacerbation of chronic bronchitis. In one patient the diagnosis of LRTI could not be confirmed. In approximately 50% of the patients a microbiological diagnosis could be made. The most important isolated pathogens from sputum and blood were (positive blood cultures in brackets): Streptococcus pneumoniae 14 (9) and Haemophilus influenzae 16. Mean duration of i.v. therapy was 7.4 days in both groups. Average duration of hospitalisation was 15.0 days for CTX patients and 15.9 days for STD patients. Overall cure and improvement rate at the end of treatment was 47 (90%) for patients receiving ceftriaxone 1 g compared to 37 (77%) for patients receiving standard therapy. Pathogens were eradicated or presumed to be eradicated in 84% of the CTX patients and in 76% of the STD patients. Mean total costs per treatment were lower for CTX than for STD treatment: NLG 169 versus 458. These results show, that i.v. ceftriaxone 1 g once daily is as effective as standard therapy in the treatment of LRTI and that its use reduces treatment costs, in view of the multiple daily dosing regimens of most standard therapies.