Patient perceptions of ICU physiotherapy: 'Your body needs to go somewhere to be recharged '.

Background: Patient satisfaction is an essential concept to consider for the improvement of quality care in healthcare centres and hospitals and has been linked to increased patient compliance with treatment plans, better patient safety and improved clinical outcomes. Objectives: As part of a before-and-after clinical trial aimed to investigate the implementation of an evidence-based and -validated physiotherapy protocol within a surgical intensive care unit (ICU), we decided to include the patient perception of physiotherapy received in the intervention unit. Methods: A nested, exploratory, descriptive, qualitative study design was adopted. Purposively selected adult patients discharged from ICU during the implementation phase of the trial were interviewed. Results: Eighteen patients (10 male) with a median age of 44 years and median ICU length of stay (LOS) of six days were included. Three themes and nine categories emerged: (i) linking therapy to clinical outcome (patient expectations and understanding; physiotherapy activities and the implication of mobilisation; physiotherapy benefits and progression); (ii) the importance of developing a trusting relationship (physiotherapy value; safety; continuity of care); and (iii) communication (satisfaction; interactions and patient perception and experience of physiotherapy). Conclusion: While confirming barriers to early mobility, patients perceived participation in mobility activities as a marked jolt in their journey to recovery following a critical incident. Effective communication and preservation of trust between physiotherapist and patient are essential for understanding expectations and can facilitate improved outcomes. Clinicians can use the information when managing critically ill patients. Including patient-reported outcomes to measure physiotherapy interventions used in the ICU is feasible and can inform the development of such outcomes. Contribution of the study: The study highlights the feasibility and importance of the use of patient-reported outcomes to measure physiotherapy interventions and informs the development of patient reported outcomes and the importance of patient centred physiotherapy care in the ICU setting.

Prevalence of orthostatic hypotension and relationship with drug use amongst older patients.

INTRODUCTION: Orthostatic hypotension (OH) is said to be highly prevalent in older people. Drugs are often involved as causative factor. Nevertheless, few data are available about the prevalence of OH and its relationship with drugs in olders. OBJECTIVES: To review data about (i) the prevalence and characteristics of OH in older patients; and (ii) the relationship between OH and drugs. METHODS: Review of publications from Ovid (PubMed) from 1980 to May 2011 using the following key words: "orthostatic hypotension" combined with "elderly" or equivalent for the analysis of prevalence (first search) and "orthostatic hypotension" combined with "drugs" or equivalent to assess the relationship between OH and drugs (second search). RESULTS: Fifty-one publications (of which 14 with original data) were retrieved from the prevalence search, 31 for the second search (8 with original data: 7 retrospective studies and 1 prospective cohort study) and 12 reviews or experts opinions. Prevalence of OH varies according to the characteristics of the subjects, the settings of the studies, and the procedures of blood pressure measurement. In acute geriatrics units, two studies reported a prevalence of over 30% and one study mentioned that 68% of the patients presented with at least one episode during the day. OH was associated with several geriatric problems: gait disorders, balance disorders, falls, cerebral hypoperfusion, transient ischemic attacks, cognitive impairment, acute myocardial infarct and systolic hypertension. OH can also be asymptomatic or with atypical presentation: falls, gait disorders and confusion. Psychotropic agents (antipsychotics, sedatives, antidepressants), and cardiovascular drugs (antihypertensive agents, vasodilators, diuretics) were associated with OH. DISCUSSION: If the hypothesis of causality between drug treatment and OH is confirmed, the identification of the involved drugs could be of value for the prevention of OH and its complications. In this context, the Working Group Pharmacology Pharmacotherapy and Pharmaceutical Care of the Belgian Society of Gerontology and Geriatrics proposes to conduct a multicentre study to assess the prevalence of OH in Belgian acute geriatrics units and its relationship with drugs.

EORTC workshop on clinical trial methodology in older individuals with a diagnosis of solid tumors.

BACKGROUND: Due to the aging of the population, the number of older patients diagnosed with a malignant disease is increasing. A multidisciplinary approach to the senior adult cancer patient is mandatory, to assure optimal diagnosis and therapeutic management. DESIGN: European Organisation for Research and Treatment of Cancer (EORTC) has currently defined senior adult oncology as one of its priorities and has established an active Elderly Task Force (ETF). Under the auspices of the EORTC, the ETF organized a workshop on clinical trial methodology in older cancer patients and in this article, we present the conclusions of this workshop. RESULTS: Besides the 'classical' efficacy end points, quality of life, functional status and independence of the patient should be assessed in clinical trials in older patients. The participants of the workshop agreed on the use of a minimum dataset for the assessment of global health and functional status in older cancer patients. The panel also recommended that optimization of collaboration with pharmaceutical industry requires reporting of age-related data (subgroup analyses of clinical trials, age-related pooled analyses and obligatory post-marketing studies in vulnerable and frail older patients). CONCLUSION: The identification of proper clinical outcomes and the validation of geriatric screening tools are needed for conducting sound and comparable clinical trials.

Palliative care for the geriatric patient in Europe. Survey describing the services, policies, legislation, and associations.

BACKGROUND: Knowledge about the quality of end-of-life care in the elderly patient in Europe is fragmented. The European Union Geriatric Medicine Society (EUGMS) Geriatric Palliative Medicine (GPM) Interest Group set as one of its goals to better characterize geriatric palliative care in Europe. OBJECTIVE: The goal of the current study was to map the existing palliative care structures for geriatric patients, the available policies, legislation, and associations in geriatric palliative medicine in different countries of Europe. METHODS: A questionnaire was sent to Geriatric and Palliative Medicine Societies of European countries through contact persons. The areas of interest were (1) availability of services for the management of geriatric patients by using vignette patients (advanced cancer, severe cardiac disease, and severe dementia), (2) policies, legislation of palliative care, and (3) associations involved in geriatric palliative medicine. RESULTS: Out of 21 countries contacted, 19 participated. Palliative care units and home care palliative consultation teams are available in most countries. In contrast, palliative care in long-term care facilities and in geriatric wards is less developed. A disparity was found between the available services and those most appropriate to take care of the three cases described in the vignettes, especially for the patient dying from non-malignant diseases. The survey also demonstrated that caregivers are not well prepared to care for the elderly palliative patient at home or in nursing homes. CONCLUSION: One of the challenges for the years to come will be to develop palliative care structures adapted to the needs of the elderly in Europe, but also to improve the education of health professionals in this field.

Treatment of a nephrotic syndrome by endoscopic removal of a villous adenoma of the duodenum.

We report the case of a patient diagnosed with a villous adenoma of the duodenum showing high degree dysplasia who developed a nephrotic syndrome (NS) due to a membranous nephropathy (MN), demonstrated by renal biopsy. Only the endoscopic resection of the duodenal adenoma could control the NS. The first manifestation of a MN is often the development of a NS. Up to 20% of patients older than 65 years who develop a MN have cancer. Tumours most often identified are those of lung, prostate and digestive tract. A renal biopsy is required to identify this type of nephropathy. If a diagnosis of MN is made, an associated tumour should be looked for.

EORTC elderly task force position paper: approach to the older cancer patient.

As a result of an increasing life expectancy, the incidence of cancer cases diagnosed in the older population is rising. Indeed, cancer incidence is 11-fold higher in persons over the age of 65 than in younger ones. Despite this high incidence of cancer in older patients, solid data regarding the most appropriate approach and best treatment for older cancer patients are still lacking, mostly due to under-representation of these patients in prospective clinical trials. The clinical behaviour of common malignant diseases, e.g. breast, ovarian and lung cancers, lymphomas and acute leukaemias, may be different in older patients because of intrinsic variation of the neoplastic cells and the ability of the tumour host to support neoplastic growth. The decision to treat or not these patients should be based on patients' functional age rather than the chronological age. Assessment of patients' functional age includes the evaluation of health, functional status, nutrition, cognition and the psychosocial and economic context. The purpose of this paper is to focus on the influence of age on cancer presentation and cancer management in older cancer patients and to provide suggestions on clinical trial development and methodology in this population.

The academic environment: the students' perspective.

Dental education is regarded as a complex, demanding and often stressful pedagogical procedure. Undergraduates, while enrolled in programmes of 4-6 years duration, are required to attain a unique and diverse collection of competences. Despite the major differences in educational systems, philosophies, methods and resources available worldwide, dental students' views regarding their education appear to be relatively convergent. This paper summarizes dental students' standpoint of their studies, showcases their experiences in different educational settings and discusses the characteristics of a positive academic environment. It is a consensus opinion that the 'students' perspective' should be taken into consideration in all discussions and decisions regarding dental education. Moreover, it is suggested that the set of recommendations proposed can improve students' quality of life and well-being, enhance their total educational experience and positively influence their future careers as oral health physicians. The 'ideal' academic environment may be defined as one that best prepares students for their future professional life and contributes towards their personal development, psychosomatic and social well-being. A number of diverse factors significantly influence the way students perceive and experience their education. These range from 'class size', 'leisure time' and 'assessment procedures' to 'relations with peers and faculty', 'ethical climate' and 'extra-curricular opportunities'. Research has revealed that stress symptoms, including psychological and psychosomatic manifestations, are prevalent among dental students. Apparently some stressors are inherent in dental studies. Nevertheless, suggested strategies and preventive interventions can reduce or eliminate many sources of stress and appropriate support services should be readily available. A key point for the Working Group has been the discrimination between 'teaching' and 'learning'. It is suggested that the educational content should be made available to students through a variety of methods, because individual learning styles and preferences vary considerably. Regardless of the educational philosophy adopted, students should be placed at the centre of the process. Moreover, it is critical that they are encouraged to take responsibility for their own learning. Other improvements suggested include increased formative assessment and self-assessment opportunities, reflective portfolios, collaborative learning, familiarization with and increased implementation of information and communication technology applications, early clinical exposure, greater emphasis on qualitative criteria in clinical education, community placements, and other extracurricular experiences such as international exchanges and awareness of minority and global health issues. The establishment of a global network in dental education is firmly supported but to be effective it will need active student representation and involvement.

Does the mini nutritional assessment predict hospitalization outcomes in older people?

BACKGROUND: the Mini Nutritional Assessment is a validated clinical tool for the assessment of nutritional status in older people. Moderate to severe malnutrition is common in elderly patients in hospital and is associated with a poor outcome. OBJECTIVES: to determine whether the Mini Nutritional Assessment can predict the outcome of hospital stay in older individuals. SETTING: a tertiary-care geriatric hospital. METHODS: we evaluated nutritional status using the Mini Nutritional Assessment in 1319 patients (mean age 84.2, 70% women) admitted between February 1996 and January 1998; 1145 complete assessments were available for analysis. The assessment was carried out on admission and studied in relation to length of stay and in-hospital mortality for all patients, and discharge to a nursing home for those living at home before admission. RESULTS: Mini Nutritional Assessment scores averaged 19.9+/-3.8 (mean+/-SD) with a range of 8.0-27.5, and a median of 20.5. A score below 17, corresponding to malnutrition, was associated with an almost threefold increase in mortality and in the rate of discharge to a nursing home; this contrasted with a score above 24, which indicates satisfactory nutritional status (11.3% vs 3.7%; P<0.01 and 20.3% vs 7.7%; P<0.001, respectively). Length of stay was longer in the low scoring group (42.0 days vs 30.5 days; P<0.0002). CONCLUSION: Poor nutritional status as measured by the Mini Nutritional Assessment was associated with increased in-hospital mortality, a higher rate of discharge to nursing homes and a longer length of stay.

[Collaboration between the geriatrician and the surgeon: a major contribution for the aged patient in rehabilitation]. / La collaboration entre le gériatre et le chirurgien: un intérêt majeur pour le patient âgé en rééducation.

BACKGROUND: Subtrochanteric fractures are complex fractures requiring prudent reeducation. In elderly patients who also have other illnesses, reeducation of walking may be quite difficult. CASE REPORT: An 89-year-old woman was referred for physical therapy after osteosynthesis of a comminutive subtrochanteric fracture. Weight bearing was contraindicated for 3 months due to her "incapacity to perform reeducation exercises". The patient also had several serious co-morbidities which had to be integrated into the reeducation program. DISCUSSION: In cases of complex fractures, reeducation must take into account other comorbid conditions. Outcome can be favorable, but requires a well organized interdisciplinary approach associating the geriatrics and the orthopedics teams.

[Innovative teaching, a successful invention: the European Academy for Medicine of Ageing (EAMA). The viewpoint of teachers and students]. / Un enseignement innovant, une création réussie: l'European Academy for Medicine of Ageing (EAMA). Le point de vue des enseignants et des étudiants.

INTRODUCTION: The origins of the EAMA (European Academy for Medicine of Aging) course are described in this paper by the Scientific Committee of this new post-graduate teaching activity. CURRENT KNOWLEDGE AND KEY POINTS: Innovations are constantly introduced to improve training methodology so as to enable the students to update their knowledge, help them improve their skills in data gathering and in the critical interpretation of information, and exchange geriatric experience and know-how. To reach such goals, an interactive teaching method is implemented by the professors, with world experts being called in to ensure scientific soundness and quality. Evaluations by students and teachers are regularly carried out with the aim of perfectly adjusting their training methodologies and increasing the scientific level of exchanges. FUTURE PROSPECTS AND PROJECTS: If the students progress, so do the teachers....

"Weight loss preoccupation in aging women": a review.

Preoccupation with body weight leading to frequent dieting has been found to be common in young women of developed countries. Little is known however about body image preoccupation or the prevalence of dieting for weight control purposes in elderly women. The few available reports suggest that preoccupation with weight remain high in elderly women and that pressure to be thin drives normal weight older women to recurrent dieting. After a reminder of the nutritional vulnerability of the elderly recommendations to the health care professionals and health authorities are provided. An increased awareness of eating habits and weight preoccupation in elderly women is needed, since attitudes towards weight may influence the effectiveness of medical advice and health promotion campaigns.

Coronary vasospasm as a source of false positive results during dobutamine echocardiography.

BACKGROUND: Several studies have demonstrated a consistently high sensitivity of dobutamine echocardiography whereas test specificity in these series has been variable. The aim of this study was to evaluate whether coronary vasospasm--elicited by alpha1 adrenoreceptor stimulation--may be a significant source of false positive responses during dobutamine stress. METHODS: From the data bank of four institutions we selected 113 patients (75 males, 38 females, mean age 55 +/- 12 years) with dobutamine echocardiography performed (up to 40 micrograms/kg/min and atropine 1 mg if needed) before a coronary angiography showing normal or near normal (visually assessed stenosis severity < 50%) coronary arteries. The following variables--which were previously reported influencing dobutamine echo specificity--entered the multivariate statistical analysis: age, sex, heart rate at baseline and at peak stress, baseline echo, hypertension, site of asynergy, and spasm at coronary angiography. RESULTS: Twenty-five patients had a positive dobutamine test. The positivity occurred in the left coronary territory in 15 and in the right coronary territory in 10 cases. All the 6 patients with spontaneous spasm during angiography had a false positive stress test result. By multivariate analysis only coronary artery spasm during angiography (p = 0.0015) and history of hypertension (p = 0.0031) were significant predictors of false positive results of dobutamine stress echocardiography. CONCLUSIONS: Coronary artery spasm may be an important source of false positive results during dobutamine stress echocardiography.

[The thyroid in the aged subject]. / La thyroïde du sujet âgé.

Thyroid disorders are common in an elderly hospitalized population. They are mainly due to multiple concurrent illnesses present in these patients or the drugs prescribed. The pathophysiology of these non-thyroidal illnesses is explained. These disorders must be distinguished from overt thyroid diseases such as hypo- or hyperthyroidism. The symptoms of which are often atypical compared to the young. Specific geriatric assessment of these symptoms and the treatment of the thyroid diseases are reviewed. Lastly, the occurrence of thyroid nodules and thyroid cancers must be managed taking into account the clinical status of the patient.

Impact of chronic patency of infarct-related coronary artery on prevalence of myocardial ischemia during the pharmacologic and exercise stress test.

BACKGROUND: Even late restoration of anterograde coronary flow may have beneficial effects on left ventricular function, electrophysiology, and survival in postinfarction patients. HYPOTHESIS: The patency or occlusion of an infarct-related coronary artery in the chronic phase may also be associated with myocardial ischemia provoked by pharmacologic and physiologic stress tests. METHODS: High-dose dipyridamole echocardiography test (DET) (up to 0.84 mg/kg over 10 min), exercise electrocardiography (EET), and coronary angiographic data in a group of 127 in-hospital patients who had survived an acute myocardial infarction were analyzed. Patients who had only angiographic evidence of infarct-related single artery disease (> or = 50% luminal diameter reduction) and no previous revascularization were enrolled in the study. DET and EET were performed (DET in all, EET in 118 patients) within 5 days before coronary angiography. Fifty-seven patients had total occluded infarct arteries (Group 1) with various degrees of collateral circulation (2.6 +/- 1.1 collateral score, by a 3 grading system), whereas the other 70 patients had patent infarct arteries (Group 2) with significant residual stenoses (82 +/- 13% diameter reduction). RESULTS: The prevalence of rest angina or effort angina and topography of the infarct-related coronary artery did not differ between the two groups (all p = NS). There were more patients with Q wave in Group 1 than in Group 2 (72 vs. 57%, p = 0.08) compared with non-Q wave infarction (Group 1 = 28 vs. Group 2 = 43%, p = 0.08). Ischemia in the infarct-related artery territory detected by DET (defined as new wall motion dyssynergy or marked worsening of resting hypokinesia) was 61% in Group 1 and 41% in Group 2 (p = 0.025). EET was positive in 26 of 54 (48%) Group 1 and in 21 of 64 (33%) Group 2 patients (p = 0.09). CONCLUSIONS: Patients with occluded infarct-related arteries have a higher prevalence of ischemia during DET and EET regardless of the presence of collateral flow. These results suggest that the presence of partial anterograde flow in the prolonged period could have a favorable influence on prevalence of residual ischemia in these patients.

Evaluation of a quantitative food frequency questionnaire used in a group of Norwegian adolescents.

OBJECTIVE: The study was conducted to assess the reproducibility and validity of a 190-item self-administered quantitative food frequency questionnaire, used in a nation-wide study of adolescents. DESIGN AND SUBJECTS: Reproducibility study; 103 11th grade students (18 years) completed the questionnaire twice, with a 6-week interval. Validation study; 49 11th grade students filled in the questionnaire and kept 7-day weighed food records. RESULTS: Spearman rank correlations between the nutrient intakes from the two questionnaires varied from 0.63 (sugar energy percentage) to 0.91 (alcohol). The median coefficient was 0.85. The first questionnaire produced generally higher nutrient intake estimates than the second. Correlations between nutrient intake values from the records and the questionnaire ranged from 0.14 (vitamin D, non-significant, cod liver oil not included) to 0.66 (monounsaturated fatty acids). The median coefficient was 0.52. Adjustment for energy intake did not materially affect the correlations. On average 41% of the subjects were classified in the same quartile in the questionnaire and the records, and 2% in the opposite quartiles. However, the percentage of subjects in the same/opposite quartiles for vitamin D and fibre were 33/12 and 22/6, respectively. CONCLUSIONS: It is concluded that the questionnaire is able to rank subjects according to the tested nutrients, except vitamin D and fibre.

Dietary intake among Norwegian adolescents.

OBJECTIVE: The aim of the nationwide study on dietary behaviour of adolescents was to describe and evaluate dietary habits, and relate that to other lifestyle factors. DESIGN AND SUBJECT: 1564 students in secondary schools completed a self-administered quantitative food frequency questionnaire in a school setting. RESULTS: The questionnaire showed an average energy intake of 15.8 and 9.9 MJ among boys and girls, respectively. Nearly 31% of the energy was supplied by fat and 11.4% by sugar. The average daily intake of micronutrients exceeded the Norwegian recommendations, except for vitamin D and iron in girls. 13.4% of the students had breakfast twice a week or less. These students had a higher percentage of energy from fat and sugar, and a lower intake of micronutrients, than students eating breakfast more often. Students who were daily smokers or fairly inactive had higher energy percentage from fat and sugar and lower intake of fibre, than non-smokers or physically active students. CONCLUSION: Half of the students consumed a diet with too much fat and two-thirds consumed too much sugar as compared to the recommendations. The girls had a diet with a higher nutrient density and a lower fat energy percentage than the boys. Finally, it seemed as if a healthy lifestyle was associated with a healthy diet.

Magnesium status in healthy free-living elderly Norwegians.

OBJECTIVE: Magnesium (Mg) status has previously not been properly assessed among healthy elderly subjects. METHODS: Thirty-six healthy elderly subjects participated. Their Mg status was assessed by serum Mg, basal urinary Mg output, and with a Mg loading test (30 mmol infused during 8 hours; urine sampled 24 hours), and compared with 53 healthy younger subjects. Their dietary intake was assessed by a quantified food frequency questionnaire. Fourteen of the subjects received 300 mmol Mg to study the effect on Mg status. RESULTS: With the exception of vitamin D in women, average energy and nutrient intakes were adequate. All subjects had serum Mg levels within the reference value of the laboratory. Basal urinary Mg excretion was 3.3 +/- 1.1 mmol/day and 24-hour Mg retention after a Mg load was 28 +/- 16% compared to 6 +/- 11% in younger controls, suggesting Mg deficiency in the elderly. In the 14 subjects who received oral Mg supplementation there was a statistically significant increase in basal urinary Mg excretion and creatinine clearance, and decreases in Mg retention, serum Mg and serum creatinine. CONCLUSIONS: This study suggests that a significant subclinical Mg deficit, not detected by serum Mg, was present in many of these healthy elderly subjects. Mg supplementation improved Mg status and renal function.